Medical Authorization Form

Athlete Name *
Athlete Name
Parent/Guardian Phone *
Parent/Guardian Phone
Called ONLY if parent/guardian is unreachable
Emergency Contact Phone *
Emergency Contact Phone
I hereby authorize and consent to the administration of any and all medical, dental, and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia and/or blood transfusions to the above named minor person that may be ordered by a physician and/or dentist in attendance at the medical center deemed necessary for emergency treatment. I here by consent to the release of medical report(s) to any doctor or agency and consent to the admission of the above named minor person to the hospital. *
I understand that The Milwaukee Rowing Club and its officers, employees and volunteers assume no financial obligation or liability in the case of my child’s accident or illness. If I, or anyone on my or my child’s behalf makes a claim against The Milwaukee Rowing Club or their officers, employees or volunteers arising from to my child’s participation in The Milwaukee Rowing Club programs, I agree to indemnify and hold them harmless from any litigation expenses, attorneys’ fees, loss, liability, damage or costs they may incur due to the claim made against any of them, whether the claim is based on their negligence or otherwise. I sign this agreement on my child’s behalf, my behalf and on behalf of my personal representatives, assigns, heirs and next‐of‐kin. I hereby give my permission for emergency treatment for my child and assume financial responsibility for such treatment. *
By entering my name and pressing "Submit" I electronically sign this Medical Authorization Form *
By entering my name and pressing "Submit" I electronically sign this Medical Authorization Form
Date *
Date