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Rex Putnam Cheerleading Medical Form

This medical release form enables healthcare providers and volunteers to treat a minor child participating in Rex Putnam cheerleading. It collects information including the child's name, birthdate, grade, guardian's name and contact details, allergies, medications, insurance, and provides consent for medical treatment. The parents acknowledge that cheerleading involves physical activity and injury risks, but that their child is able to participate, and waive liability for any damages occurring during participation.

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rp_youthcheer
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65 views1 page

Rex Putnam Cheerleading Medical Form

This medical release form enables healthcare providers and volunteers to treat a minor child participating in Rex Putnam cheerleading. It collects information including the child's name, birthdate, grade, guardian's name and contact details, allergies, medications, insurance, and provides consent for medical treatment. The parents acknowledge that cheerleading involves physical activity and injury risks, but that their child is able to participate, and waive liability for any damages occurring during participation.

Uploaded by

rp_youthcheer
Copyright
© Attribution Non-Commercial (BY-NC)
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd

Rex Putnam Cheerleading Medical Release Form

This completed form will enable health facilities and RP cheerleading volunteers to provide care to your
minor child. All Areas of This Form Must Be Completed
Participants Name ____________________________________________
Birth Date ________________________ Grade- 1 2 3 4 5 6 7 8 (Circle one)
Guardians Name/Relationship
__________________________________________________________________
[ ] No [ ] Yes Allergic Reactions (drugs, food, asthma)___________________________
______________________________________________________________
[ ] No [ ] Yes Taking any medication at this time
_____________________________________________________
If yes, please describe
______________________________________________________________________
Date of last tetanus shot _____________________________
In Case of Emergency _______________________________
Father Home Telephone _____________________________
Father Work Telephone ______________________________
Mother Home Telephone ______________________________
Mother Work Telephone _______________________________
Other Emergency Number (List person to contact)
_____________________________________________________________________
Your Insurance Company ________________________________________________
Policy # ______________________________________________________________
Name of Policy Holder __________________________________________________
Any instructions regarding your insurance
___________________________________________________________
I/We, the undersigned hereby certify that I (we) am (are) the parent or legal guardian of the participant. I
hereby give permission for the volunteers of the Rex Putnam Cheerleading Squad to seek, during the
period of the cheerleading clinic, appropriate medical attention for the participant and for medical attention
to be given and for the participant to receive medical attention in the event of accident, injury, or illness.
I (we) will be responsible for any and all costs of medical attention and treatment.
I/We, the undersigned, for ourselves and as the guardians of
________________________________________ (Participants Name) understand that cheerleading is
an active, physical sport, and that injuries can take place during play.
I/We understand that, as with any sport, injuries can occur, and we hereby acknowledge that our child is
physically fit and mentally capable of participating in cheer activities.
I/We also understand that it is my/our responsibility in caring for the participant listed above, and to be
assured that he/she is fully capable of engaging in this sports activity, and I/we are confident that he/she
is able to engage in such a sport.
I/We, the undersigned for ourselves, our heirs, executors and administrators, waive, release and forever
discharge Rex Putnam Cheer, its coaches, staff members and others working with my child, from all rights
and claims for damages, injury, or loss to person or property which may be sustained or occur during
participation in cheer activities, whether or not damages, injury, or loss is due to negligence.
Signature of Parent or Guardian __________________________________________________________
Date______________________

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