Kickball Medical Information Form 2024

Night in the Dome Kickball Tournament | Friday, March 22, 2024
All players must complete the following form before a student arrives at the tournament.

Church Name

Team Name (if known)

STUDENT INFORMATION

Student's First Name

Student's Last Name

Student's Email Address

Cell Phone:

May we text you?

Yes

No

Birthdate

Address

Country

Street

City

Region

Postal Code

Gender

Female

Male

High School Name

Graduation Year

HS CEEB (Hidden)

HS Level of Study (Hidden)

MEDICAL INFORMATION (Filled out by parent/guardian)

Please list any of the following items that may impact your participation:

Medical conditions
Medications that the youth will be bringing to the tournament
Any known allergies

Emergency Contact Name

Emergency Contact Phone Number

Can first aid such as ice packs and band aids be administered?

Yes

No

Can over-the-counter medicines such as Tylenol, antacid or triple antibiotic be administered?

Yes

No

Hospital Insurance?

Yes

No

Please list your insurance company and policy number:

I certify that I have read the above information. Any questions concerning these policies have been discussed.

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to an X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs. The undersigned does also hereby give permission for our(my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Concordia University.

I give permission for any pictures or videos taken during the Kickball Tournament to be used at the discretion of Concordia University, the students, faculty, staff, or other representatives. I release and forever discharge Concordia University, their agents and servants, successors and assigns directors, trustees, officers, employees, and other representatives against loss from any and all present or future claims, demands or actions in law or in equity that may hereafter be made or brought by me or my child, by anyone on behalf of me or my child, or by anyone else on their own behalf for damages or any other legal or equitable remedy on account of any injury, illness, physical condition, inconvenience, or loss sustained by my child during the planned activities for which my child is registering to participate.

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Kickball Medical Information Form 2024