*MUST BE FILLED OUT & RETURNED (1 PAGE)

NYACK COLLEGE PARENTAL MEDICAL RELEASE FORM

Nyack Colleges Athletic Program is an integral part of the curriculum, and college personnel have devoted great effort to assure the participating students are protected in every way possible. However, participation in athletics includes a risk of injury that may range in severity from minor to long-term catastrophic, including paralysis and death. Participants have the responsibility to help reduce the chance of injury. Participants must obey all safety rules and regulations, report all physical problems to the Athletic Trainer and the Coach, follow through on treatment and rehabilitation of injuries, follow a proper conditioning program and inspect personal protective equipment daily. Proper execution of skill techniques must be followed for every sport, especially in contact sports. Parent/guardian initials & signature is required if the student-athlete is covered by medical insurance through the parent/guardian &/or they are claim as a dependant even if they are over 18 years of age.
ATHLETES INITIALS PARENT/ GUARDIAN INITIALS

PARENT(S)/GUARDIAN(S)/ATHLETE, PLEASE INITIAL EACH STATEMENTS TO SHOW THAT THE STATEMENT HAS BEEN READ, UNDERSTOOD & APPROVED
I the athlete and I the parent/guardian, consent to have me, my son/daughter represent Nyack College in approved athletic activities except those activities excluded by the examining doctor. I understand that injuries are an inherent part of athletics and that try-out for and/or participation in sports requires an acceptance of risk of injury, thus there is a risk that I, my son/daughter may be injured while playing or practicing in an intercollegiate sport. I understand that these personal injuries include, but not limited to, death, serious neck and spinal injuries, and further that such injuries may result in complete or partial paralysis, brain damage, and serious injury or impairment to virtually all internal organs, bones, joints, ligaments, muscles, tendons, and other aspects of the muscular skeletal system and serious injury or impairment to other parts of the body, general health and well-being. I understand that the dangers and risks of playing or practicing to play or participating in any sports or athletic activity may result not only in serious injury, but in a serious impairment of my/son/daughters future capacity to earn a living, to engage in other business, social and recreational activities and generally, to enjoy life. I grant permission for me, my son/daughter to accompany any college team of which he/she is a member to out-of-town trips. The athlete will be transported to and from all events in college approved vehicles. Parents wishing to have their son/daughter with them when returning from an event must make arrangements with the coach. I hereby grant permission to Nyack College Team Physicians and/or consulting physicians to render me, my son/daughter, any treatment or medical or surgical care that they deem necessary to me, my son/daughter health and well-being. I also hereby authorize the Athletic Trainers at Nyack College, who are under the direction and guidance of the Nyack College Team Physician, to render me, my son/daughter any preventative, first aid, rehabilitation or emergency treatment that they deem reasonably necessary to me, my son/daughter health and well-being. In the event of an emergency requiring medical attention, I expect every reasonable attempt be made to contact me. In case I cannot be reached, I grant permission for any immediate treatment deemed necessary by the attending physician and transfer of me, my son/daughter to a qualified medical facility. This authorization does not cover major surgery unless deemed necessary by two licensed physicians or dentists. I agree not to hold Nyack College or anyone acting on its behalf, responsible for any injury occurring to me, my son/daughter in the proper course of such athletic activities or travel. I further agree for myself/son/daughter and on behalf of my/his/her heirs, personal representative(s) and assigns to defend, hold harmless, indemnify, release, and forever discharge Nyack College and anyone acting on its behalf from and against any and all claims, demands and actions, or causes of action, on account of damage to personal property, personal injury or death which may result from my participation, or from causes beyond the control of, and without the fault or negligence of Nyack College, and anyone acting on its behalf, during the period of my enrollment or participation as aforesaid. I further acknowledge and understand that it is my responsibility to continue to notify the Nyack College Athletic Trainer of any limitations on my medical condition through my enrollment or participation in sports or athletic activities at Nyack College. I further acknowledge and understand that if I refuse or fail to treat and/or rehab my injury, I maybe removed from athletics. I further acknowledge that if I go to a doctor I must get a clearance note from that doctor and the Team Physician stating that I am cleared to participate in intercollegiate athletics, before I return to athletics at Nyack College. Knowing that my insurance, the Nyack College student medical insurance and/or the Nyack College athletic insurance may refuse coverage due to my failure to treat my injury, I will be responsible to pay for the medical bill incurred for treatment of the injury by the Team Physician and/or other medical services myself/son/daughter seek on their own. I acknowledge and accept that there are risks of physical injury involved in athletic participation that may result in permanent paralysis, mental disability, and death.

Please make sure both the athlete and the parent/legal guardian has initialed
DATE________________________

8 boxes!

SIGNATURE__________________________________________
PARENT/LEGAL GUARDIAN

DATE________________________

SIGNATURE__________________________________________
ATHLETE