Who is completing this form?
Your Name *
Your Email *
Player Name *
Player Birthdate *
Address *
Primary Contact Name *
This is who we will contact first in the event of an emergency. Must be 18 or older.
Relationship to the Player *
Primary Contact Phone *
Does this number accept text messages? *
Secondary Contact Name *
If the primary contact is unreachable, we will contact this person next
Secondary Contact Phone *
Has your player ever had, or have now: (select all that apply) *
If you selected any of the above, please provide details.
In the past year, my player has experienced: (select all that apply)
List any previous sports injuries, approx. dates, and whether or not it is still a problem. *
List any previous concussions, approx. date(s), and circumstance(s) as accurately as possible. *
Known allergies: (select all that apply) *
List any medications (prescription or non-prescription) that the player takes regularly and their purpose. Include inhaler and epi-pen, if applicable. *
I consent to have this information shared with the coaches, and if necessary, on-site medical personnel, paramedics or other first responders, or hospital staff. *
I agree
I will ensure that the appropriate asthma or allergy medication is brought with the player and available to Coach Morgan prior to all training, games, travel tournaments, and club activities.If medication is not available, player will be unable to partici *
Information regarding my player's allergies and/or prescribed medication, if any, is documented herein. I agree to promptly notify Coach Morgan of any changes in my player's prescribed medications. *
Consent to administer medication *
If my player visits a doctor for any type of physical injury during season, I will provide a statement or note from the doctor, addressed to Coach Morgan, indicating that the player is released for practice/play. *
In the event your player should need emergency care, please provide the information below:
Medical Insurance Name *
Policy/Member ID *
Policy Holder's Name *
Physician's Name and Phone *
I authorize personnel to call 911 for Emergency Medical Services and I give permission for the above-named player to be transported to the hospital. *
Consent to treat *
Pursuant to the requirements of the Health Insurance Portability and Accountability Act of 1996 and the regulations promulgated thereunder (collectively known as “HIPAA”), I authorize healthcare providers of the above-named player, including emergency medical personnel and other similarly trained professionals that may be attending an event or practice, to disclose/exchange essential medical information regarding the injury and treatment of this player to appropriate personnel such as but not limited to: Athletic Facility Director, Athletic Facility Trainer, Team Coach, Team Manager and/or other professional healthcare providers, for purposes of treatment, emergency care and injury record-keeping.
As the parent/legal guardian of the athlete named in this form,
I hereby grant permission for my child to participate in the Morgan Dawgs Elite Basketball program.
I hereby state that the above information is correct, and I will hereby notify Coach Morgan if any changes occur.
I understand that Morgan Dawgs Elite Basketball does not provide any accident or health insurance coverage for my child while participating in competitive athletics. I fully understand that it is my responsibility to provide insurance coverage for my child.
While participation in supervised activities/athletics may be one of the least hazardous activities in which any athlete participates in, by its nature, participation in competitive athletics includes a risk of injury (up to and including serious permanent injury or death). I agree to release, discharge, and hold harmless Morgan Dawgs Elite Basketball, its officers, Coach Ed Morgan, team coaches, volunteer staff, representatives, and The Courts Sports Complex from any and all claims, demands, causes of action, or liability arising out of my child’s participation in the Morgan Dawgs Elite Basketball program.
I hereby grant permission for my child to receive medical treatment in case of an injury during a practice or game from the coaches or facility medical trainer. I understand that any Medical Staff working with me or my child does not assume any financial responsibility in case of accident or injury while participating in sports. I understand, in case of injury, the medical staff may seek medical assistance, including ambulance service, whether covered by insurance or at my own expense. Although serious injuries are not common in supervised athletic programs, it is impossible to eliminate this risk. The participants can, and have the responsibility to, help reduce the chance of injury. Players must obey all safety rules, report all physical problems to Coach Morgan, follow a proper conditioning program, and inspect their own equipment daily.
By signing this form, we acknowledge that we have read and understood this warning. Parents or Players who do not wish to accept the risk described in this warning should not sign this form.
Player Signature *
Parent/Guardian Signature *
Please verify that you are a human.
