www.AnnandaleBbSb.org [ Home ] [ Up ]

Annandale Baseball/Softball Association 2012

***Note***

This Medical Insurance verification and authorization form must be filled out

by the player's parent or guardian and signed before the below mentioned player

will be allowed to play in any official Crow River Youth Baseball Association/Crow River Fastpitch Association games

Medical Insurance Information

NAME OF PLAYER______________________________Date Of Birth__________

Telephone___________

Please Indicate:

__YES --- My son/daughter has Medical Insurance Coverage

__NO --- My son/daughter does not have Medical Insurance Coverage

I understand the risk of injury is present while my son/daughter is participating in youth baseball and

softball. I hereby release, and agree to indemnify, defend, and hold harmless the Annandale BB/SB

Association, Annandale ISD No. 876 and their agents, including but not limited to coaches and

directors, from any and all legal liability for any injury that my son/daughter may sustain relating to or

resulting from any participation in traveling to or attendance at ATL games, practices or other

functions. My son/daughter is medically able to participate in BB/SB practices and games.

Signature of Parent/Guardian____________________________Date___________

IF MEDICAL INSURANCE COVERAGE IS PROVIDED FOR BY THE PARENT

PLEASE COMPLETE THE INFORMATION BELOW:

I (Parent)__________ the undersigned parent or guardian of (Player)_____________ do

authorize – do not authorize (circle) ATL coaches:

TO CONSENT TO any x-ray examination, medical, surgical or dental diagnosis or treatment

and hospital care to be rendered to the above named player under general or special

supervision and upon the advice of a physician, surgeon or dentist licensed under the laws of

the State of Minnesota.

IN GIVING THIS CONSENT I RECOGNIZE AND UNDERSTAND that in situations where the above

named player requires medical or hospital care it may not be possible to contact me, and that in such

situations I will not be able to knowledgably evaluate and choose among the available alternative

treatments or procedures, if any, or to evaluate the risks attendant upon each, and the risks attendant to

foregoing all treatment; in such situations, I authorize a physician, surgeon or dentist to exercise his/her

professional judgment and assess the risks incident to and choose the necessary treatment as is his/her

professional judgment determines to be necessary for the health and safety of the above named player.

Name of insurance______________________________ID#_____________

Treatment Information

Player’s doctor___________________________Clinic__________________

Hospital________________________________ Telephone______________

List any medical problems of which we should be aware:

[ Home ] [ Up ]