Date
(MM DD YYYY)
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First Name
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MI
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Last Name
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Home Phone
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Alternate Daytime Phone
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Birthdate
(MM DD YYYY)
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Age
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Family Dr.
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Parent/Gaurdian
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Email Address
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CONSENT TO TREAT
This is to certify that on
this date, I
as a
parent or guardian of ,
give my consent to XL SPORTS PROGRAM representative to obtain medical care from
any licensed physician, hospital, or clinic for the above mentioned athlete,
for any injury that could arise from participation in the XL SPORTS
PROGRAM. |
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If said athlete is covered by any insurance company,
please complete the following |
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Name of Insurance Company
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Address
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Policy Number
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Parent / Guardian Name
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Relationship to Athlete
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Home Address
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Phone
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Date
(MM DD YYYY)
|
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Also, in consideration for being
allowed to participate in the XL Sports Acceleration Program, I agree to assume
the risk of such performance enhancement exercises, and further agree to hold
harmless the XL Sports Acceleration Program, it’s staff members and
affiliates who sponsor the program from any and all claims, suits, losses, or
related causes of action for damages, including, but not limited to, such
claims that may result from my injury or death, accidental or otherwise, during
or arising in any way from the XL Sports Acceleration Program.
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