MILWAUKEE FIELD HOCKEY CLUB MEDICAL AND LIABILITY RELEASE FORM

Athlete Name *
Athlete Name
Date of Birth *
Date of Birth
Address
Address
Parent Cell Phone Number
Parent Cell Phone Number
Emergency Contact Information
Telephone Number
Telephone Number
Cell Phone Number
Cell Phone Number
Last Medical Check
Last Medical Check
For High School Sports Certificate
Cleared For High School Sports
Any Known Allergies or Medical Conditions
Conditions that the coaches or medical staff should be aware of in case of an accident
Milwaukee Field Hockey Medical Treatment Authorization
I certify that (or on behalf of my minor child) to the best of my knowledge, I am in good physical condition and have no disease or injury that would impair my performance or result in my being injured during any program participation. In addition, I (or on behalf of my minor child) do hereby consent to emergency medical treatment, hospitalization or other medical treatment as may be necessary for the above named athlete/child, by a certified Athletic Trainer, Physician and/or hospital in the event of an injury or illness during the periods of time in which they are participating in a Milwaukee Field Hockey program. It is understood that all costs are my responsibility. Media Release Authorization Form Milwaukee Field Hockey Club, LLC would like the opportunity to publish photographs and statements of our members for the purpose of social media marketing.In order for us to do so we would appreciate consent for you and or your child(ren). I hereby consent, authorize and assign any and all rights to Milwaukee Field Hockey Club and it’s employees to circulate news, photos, or videos of myself or my child(ren) for use in publicity releases and marketing. I further agree and consent that Milwaukee Field Hockey Club will not use any news, photos or videos of myself or my child(ren) for any purpose other than it’s official website, facebook or other social media marketing tool without my further consent. I also understand that Milwaukee Field Hockey Club LLC or it’s employees are not responsible for any misappropriation in relation to any media that has been published by Milwaukee Field Hockey Club or it’s employees by any member of the public or anyone else. I have read and understand the foregoing release, authorization and agreement and by signing below I warrant that I fully understand the contents there of. ELECTRONIC SIGNATURE AND AUTHORIZATION By checking the box underneath you agree that: (1) you have read, understand and completed the information required accurately (2) you have read and understand the Terms and Conditions.
Check Box to Agree *
Date
Date
Milwaukee Field Hockey Liability Release
In consideration of being allowed to participate in any way in the Milwaukee Field Hockey programs, related events and activities, the undersigned acknowledges, appreciates and willingly agrees that: I will comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and, I acknowledge and fully understand that each participant will be engaging in activities that involve risk or serious injury, including permanent disability and death, and severe social and economic losses which may result no only from their own actions, inactions or negligence of others, the rules of play or the condition of the premises or of any equipment used. Further, I accept personal responsibility for the damages following such injury, permanent disability or death; and, I knowingly and freely assume all such risk, both known and unknown even those arising from the negligent acts or omissions of others, and assume full responsibility for my participation; and, I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, hold harmless the Milwaukee Field Hockey Club , its officers, officials, affiliated clubs, their respective administrators, directors, agents, coaches and other employees of the organization, other participants, sponsoring agencies, advertisers, an, if applicable, owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as "releases" with respect to all and any injury, disability, death or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law.
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