Water Polo Pre Participation Physical Evaluation

Date___________Name______________________________ Sex_________ Age_________ 

Date of Birth_________________Address __________________________________ Phone # _____________________Grade________

Personal Physician_________________________  ___________________  ___________________

                                                                        Address                                 Physician Phone

 

 

 

 

Water Polo Club Participation Information

                                                                                                                                                                       

Participating                         

Student’s Name _________________________________________________ID#__________ Grade__________Birthdate_______________

                                                (Last)                                                       (First)

Parent’s Name______________________________________________Phone (Home)____________________Work___________________

 

Address_______________________________________________________________________________

 

Parent Permission to Participate:____________________________________________________________________________

                                                                                                                (PARENT SIGNATURE)

If parent(s) unavailable, please contact:________________________________________________________________________________

                                                                                                (Last)                                                                       (First)

______________________________________________________________________________________

                (Address)                                                                                   (Phone No.)                                                                            (Relationship)

In Case of Emergency, I give permission to have the team physician, paramedics, emergency room or physician listed to perform necessary medical aid:

1.Physician:________________________________________Telephone (      )_______________________

School Attended Last Year__________________________________________________________________________________

 

Medical Alert Information (Allergies, etc.)_______________________________________________

 

I/We, the undersigned, parent(s) of __________________________________________, a minor, do hereby authorize any hospital or medical center as agent(s) of the undersigned to provide any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by and is rendered under the general supervision of any physician and surgeon licensed to practice in the state of California, whether such diagnosis or treatment is rendered at the official of said physician or at said hospital.

 

It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required and is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician, in the exercise of his best judgment, may deem advisable.  This authorization is given pursuant to the provisions of Section 25.8 of the California Civil Code.  This authorization shall remain effective until ___________________20______, unless sooner revoked in writing delivered to said agent(s).

MEDICAL INSURANCE DECLARATION

I/We hereby authorize any hospital which has provided treatment to the above-named minor pursuant to the provisions of Section 25.8 of the California Civil Code to surrender physical custody of such minor to my/our above-named agent(s) upon the completion of treatment.  This authorization is given pursuant to Section 1283 of the California Health and Safety Code.

 

I am the parent (or guardian) of the above named student, a pupil in attendance (or who will be in attendance) at Sports Camp.

 

 

Medical Insurance Co._______________________Policy/Group #:_________________

Signature of parent/legal guardian__________________________________________Date___________________

 

 

 

 

 

 

 

RELEASE, WAIVER, AND INDEMNITY AGREEMENT

 

I/we, the undersigned parents of _________________________________, understand and agree that by signing this agreement, I/We absolutely release, discharge, waive, and relinquish any and all claims of loss or damage, or causes of action for all personal injury, property damage, theft or loss, associated with a our child’s participation in any of the activities in the Fullerton Hills Sports Camp.

 

Further this agreement exempts and relives; Fullerton Hills Water Polo and the Community College District including its officers, members, or employees from any and all liability of personal injury, property damage, or theft and loss of property, caused through the preparation, participation, or any action occurring with the activities of the Fullerton Hills Sports Camp on the property of the Fullerton Joint Union High School District.  The undersigned intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law. 

 

 

__________________________________________                              ___________________

Signature of Parent or Guardian                                                     Date

 

 

Please tell us where you heard about Fullerton Hills Water Polo

 

My child’s classroom             My child’s little league/sports team

 

From a friend                          Other__________________________________