BRENHAM DOLPHINS SWIM TEAM

Medical Release Form 2008

Name of Swimmer:_______________________________________Date:________________

Parental Consent

This medical release form must be signed by a parent or legal guardian for EACH swimmer of the Brenham Dolphin Swim Team.  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 BRENHAM DOLPHIN SWIM TEAM 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 BRENHAM DOLPHIN SWIM TEAM 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 #:                            

___________________________                    _____________________________