Summer League Health Form

Player Name *

First

Last

Boys or Girls Team *

Boys Team
Girls Team

High School *

Checkboxes *

By checking this box – I agree

MEDICAL LIABILITY WAIVER – I hereby grant permission for my child to participate in Ultimate Team Camps Basketball League. I also grant permission to Ultimate Team Camps and representatives to act for me according to their best judgment in any emergency requiring medical attention and hereby waive and release Ultimate Team Camps and Greenheck Fieldhouse from any and all liability for any injuries incurred while participating in the summer league.

Checkboxes *

By checking this box – I agree

CONCUSSION PARENT WAIVER-Related to Concussion Law 2011 – Wisconsin Act 172 As a Parent and Athlete, it is important to recognize the signs, symptoms, and behaviors of concussions. By signing this form you are stating that you understand the importance of recognizing and responding to signs, symptoms, and behaviors of a concussion/head injury. This form must be completed for every sports season and every youth athletic organization the athlete is involved with.

Checkboxes *

By checking this box – I agree

I have read the Parent Concussion and Head Injury Information and understand what a concussion is and how it may be caused. I also understand the common signs, symptoms, and behaviors. I agree that my child must be removed from practice/play if a concussion is suspected. I understand that it is my responsibility to seek medical treatment if a suspected concussion is reported to me. I understand that my child cannot return to practice/play until providing written clearance from an appropriate health care provider to his/her coach. I understand the possible consequences of my child returning to practice/play too soon.

By checking this box I am certifying I have legal ability to consent for the camper. I agree that all information provided is accurate to the best of your knowledge. I am over the age of 18 and I allow Ultimate Team Camps to act in the best determined interest of my child should there be contact not be possible or available. *

I consent

As the parent (guardian) of the named camper, I give permission to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named above, before taking this action. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment. I understand that the medical staff cannot provide medications (including over the counter medications). *

I consent

I also agree that my child may be transported by bus and/or camp vehicle to an off-site medical center or for emergency medical treatment. The undersigned further expressly agrees that the attached waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. *

I consent

In consideration of my minor child/ward (“my child”) being allowed to participate in this sport camp program, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that: 1. The risk of serious injury from the sports activities involved in this program is always present due to the nature of the sport (s); and 2. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s participation; and 3. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation. If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS the Camp, Ultimate Team Camps, its affiliates, officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, regarding my child and/or arising from his/her activities, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except for willful misconduct, or otherwise to the fullest extent of the law. I HAVE READ THIS HEALTH FORM AND RELATED CERTIFICATIONS, THE RELASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. *

I consent

Signature *

Clear Signature