Program & Camp Medical release form

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BROTHERS AND SISTERS EMERGING

Programing & Camp Medical Release Form

Child's First Name

Child's Last Name

Age

Parent/Guardian Name

Emergency Contact Name

Phone

Family Doctor’s Name

Phone

Doctor’s Address

Health Insurance Provider

Group #: (Optional: Only in case of emergency)

Does your health insurance have any special instructions in case of emergency that we should be aware of if you are not immediately available?

YES NO

If, yes please explain

The medical services are provided without gratuity. Therefore, we will not assume any liability due to injury on the field. If you have any medical training and would like to volunteer your time, please let us know. All are welcome.

CHILD’s HISTORY: Does your child currently have any of the following OR has your child ever been diagnosed with any of the following? Please answer YES or NO

Bleeding Tendencies

YES NO

Allergies

YES NO

Pneumonia

YES NO

Rheumatic Disease

YES NO

Bronchitis

YES NO

Anemia

YES NO

Spinal Disease

YES NO

Fractures

YES NO

Surgery

YES NO

Knee Problems

YES NO

Asthma

YES NO

Bone Disease

YES NO

Covid 19

YES NO

Does your child take any routine medications?

YES NO

Does your child have any physical handicaps?

YES NO

Any problems with vision or hearing?

YES NO

Any unusual shortness of breath?

YES NO

Any recent weight changes?

YES NO

I feel that my child is physically fit to participate in calisthenics and contact practice or scrimmages. I shall not hold the Garfield Youth Sports (GYS) football and/or cheerleading, or organizers responsible for any problems arising because of a previous health problem or injury.

Type In Your Name As Your Signature

Date

CONTACT US

(412) 404-2250

5315 Hillcrest Street Pittsburgh, PA 15224

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