Carmel Swim Club

Medical Release Form

2008-2009

Name of Swimmer:_______________________________________Date:___________________

Parental Consent

This medical release form must be signed by a parent or legal guardian for EACH swimmer of the Carmel Swim Club.  If the swimmer is 18 years of age or older, the swimmer must also sign this form.

MEDICAL RELEASE

I CERTIFY THAT, TO THE BEST OF MY KNOWLEDGE AND BELIEF, ____________________________ (NAME OF THE SWIMMER) IS IN GOOD PHYSICAL CONDITION AND HAS NO CONDITION WHICH WOULD IMPAIR PARTICIPATION IN THE PROGRAM.  IN CASE OF INJURY, I HEREBY GIVE THE CARMEL SWIM CLUB AND IT’S COACHING STAFF PERMISSION TO ACT ON MY BEHALF IN SEEKING MEDICAL TREATMENT FROM ANY LICENSED PHYSICIAN, HOSPITAL OR CLINIC FOR MY CHILD IN THE EVENT THAT SUCH TREATMENT IS DEEMED NECESSARY.  I GIVE PERMISSION TO THOSE ADMINISTERING MEDICAL TREATMENT TO DO SO USING METHODS DEEMED NECESSARY.  I ABSOLVE CARMEL SWIM CLUB AND IT’S COACHING STAFF FROM ALL LIABILITY WHILE ACTING ON MY BEHALF IN THIS REGARD

___________________________________                              ____________________________________

Participant Signature (if over the age of 18)                                  Parent/Guardian Signature:

_____________________________                          ______________________________

Home Phone:                                                                                       Parents Daytime Phone:

If parents are not available, please call the person designated below:

Name:  ________________________________________Address:  _______________________________

City/State/Zip:  ____________________________________________ Phone:  ______________________

Relationship:  ____________________________________________

Additional comments regarding medical history, allergies, penicillin or drug reactions, etc…...which may be needed in rendering medical treatment:  ____________________________________________________________________________________

 

______________________________________________________________________________________

______________________________________________________________________________________

Parent/Guardian Insurance Information:

_________________________________________                  ____________________________________

Company Name:                                                                                                Policy #:

___________________________________________________________           _____________________

Address                                                                                                                                  Phone: