Medical Release Form

    Chuck Driesell Basketball Academy Medical Release Form

    all fields are required.

    Campers Name

    BOD

    Gender

    Grade Entering

    Address

    City

    State

    zip

    Father’s Name

    Cell/Work Phone #

    Mother’s Name

    Cell / Work Phone

    Emergency Contact

    Relation

    Phone #

    Insurance Company

    Group #

    PPO/HMO/PPN

    Physician’s Name

    Physician’s Phone #

    Allergies

    Medications

    Dosage

    I certify that my child "camper" is in good health and has my permission to participate in all training activities, practices, games and camp activities at the Chuck Driesell Basketball Academy. I hereby give permission to the Chuck Driesell Basketball Academy Inc, its officers, employees, agents, athletic trainers or staff members to take whatever action is necessary for the health and welfare of my child including consenting on my behalf to any and all medical /dental treatment, procedures, operations and or hospitalization needed.

    I understand that basketball is a very physical sport, which can result in serious injury. I hereby Release and Hold Harmless the Chuck Driesell Basketball Academy Inc, its officers, employees, agents, trainers and staff members, with respect to any and all injury, liability, disability, death, loss or damage to person or property that may result from or occur during the camp week. I
    further agree to hold any of them harmless and indemnify them for all medical/dental bills incurred for the treatment of my child.

    Parent / Guardian’s Printed Name

    Parent / Guardian’s signed name

    Date