MEDICAL WAIVER
PARTICIPANT INFORMATION
Participant’s name _________________________
Street Address___________________ City ________________ Zip__________________
Allergies: _______________________
Other Medical Conditions: _______________________________________________
Participant’s Physician: __________________________Phone _________________
Medications the child might be taking: ____________________________________________
_____________________________________________________________________________
PARENT/ LEGAL GUARDIAN INFORMATION
Father’s name _____________________________ Phone __________________
Mother’s name _____________________________ Phone __________________
In an emergency when parent/ legal guardian cannot be reached or is not applicable, please contact the following:
Name ________________________ Phone ________________________
Name _______________________ Phone ___________________________
Recognizing the possibility of injury or illness, and in consideration for The Hero Within You Network Inc., accepting your child in its programs, I consent to my child participating in the programs. Further, I hereby release, discharge, and otherwise indemnify The Hero Within You Network, its member organizations and sponsors, their employees, against any claim by or on behalf of my child as a result of my child’s participation in the Programs.
I hereby represent that my child has received physical examination by a licensed medical practitioner and he/she is fit to participate in the activities of the organization. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child’s participation in the Programs.
I do not give my consent for a licensed medical doctor or dentist to provide my son/daughter with medical assistance and/or treatment. I prefer to be contacted first.
I hereby represent that I have read and understood the terms and provisions herein and agree to be bound by them.
Date: ______________________________
Signature: ________________________
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