Parental Consent

    Medical Consent Form

    all fields are required.

    Name

    Date of Birth

    Parent or Guardian

    Home Phone

    Daytime Phone (Mother)

    Cell Phone (Mother)

    Daytime Phone (Father)

    Cell Phone (Father)

    I understand that I will be contacted as soon as possible in the event that my child will need medical attention. If I am not available, please contact:

    First Emergency Contact:

    Name

    Home Phone

    Work Phone

    Car Phone

    Second Emergency Contact:

    Name

    Home Phone

    Work Phone

    Car Phone

    Medical Consent:

    I certify that my child is in good health and is physically capable of engaging in any and all activities involved in Chuck Driesell Basketball Academy.

    My child is in normal health and has permission to participate in all training activities, practices, and games. In case of an emergency or serious injury, I hereby give permission to Coach Driesell’s Basketball Academy, LLC, 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 and dental treatment. I further agree to hold them harmless and indemnify them for all medical bills incurred for the treatment of my child.

    Parent Signature

    Date

    Insurance Co.

    Policy

    Family Physician

    Phone

    Medical Information (Please fill out where applicable.)

    Allergies (Describe)

    Previous Injuries (Include Dates)

    Regular Medication Required (circle one)
    YESNO

    RELEASE AND HOLD HARMLESS AGREEMENT

    I am the Parent/Guardian of (“Participant”) who is under eighteen years of age, and I am fully competent to sign this Agreement as parent/guardian and for participant. I give permission for Participant to participate in the Chuck Driesell Basketball Academy. I acknowledge that the risk of injury from the activity involved can occur in The Chuck Driesell Basketball Academy, and while personal discipline will minimize this risk, the risk of serious injury does exist.

    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, LLC, its officers, employees, agents, trainers, staff members, with respect to any and all injury, liability, disability, death, or loss or damage to person or property, that may result from or occur during the camp week. And from liability of injury, death, or damage to property that may result from a participant’s negligent intentional act or omission while participating in the camp.

    I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTANDING ITS TERMS.

    Participant’s name

    Parent’s / Guardian’s name

    Signature of Parent or Guardian

    Date