Tiffin Catholic Baseball/Softball Organization EMERGENCY MEDICAL FORM PLAYERS NAME Phone. _ Address. PURPOSE: ‘'o enable parents/guardians to authorize the provision of emergency treatment for children who become ill or injured while participating in Tiffin Catholic Baseball/Softball events, when parents/guardians cannot be reached. I, the parent(s)/guardians of the above child hereby give my approval for his participation with Tiffin Catholic Baseball/Softball. ! acknowledge there are hazards related to these activities and I hereby waive, release, absolve, indemnify and agree to hold harmless Tiffin Catholic Baseball/Softball and Calvert Catholic Schools coaches and administrators and their representatives from any claims, damages and/or costs arising from the participation of my child in Tiffin Catholic Baseball Softball Part 1: To Grant Consent (Part I or II must be completed) In the event reasonable attempts to contact me at or ee (Phone number) (Name of parent or guardian) at ___ have been unsuccessful, I hereby give my consent for the administration of any (Phone number) treatment to ot for the participant that may be deemed reasonable and necessary by: Physician Name, Address & Phone: Dentist Name, Address & Phone: Or the transfer of the child to (Name of Hospital & Phone Number) __ —____ or any Hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance of such surgery. This authorization shall remain valid and effective for all 2010 Tiffin Catholic Baseball Softball activites. Facts concerning the child's history including allergies, medications being taken and physical impairments to which a physician /dentist should be alerted: Date: _, Signature of parent or guardian. Part I Refusal to Consent (Part I or II must be completed) TDO NOT give consent for emergency medical treatment of my child, In the event ofan illness or injury requiring ‘emergency treatment, T wish Tiffin Catholic Bascball/Softball representatives (coaches, ete.) to take the following action: Date: Signature of parent or guardian