Parental Waiver & Indemnification and Minor Medical Release Consent Form

Minor Participant Information (Player)

First Name *

Nickname (if applicable)

Last Name *

Birth Date *

Insurance Company Name *

Group Policy # *

Parent/Guardian (Primary Emergency Contact)

Primary Emergency Contact First Name(s) *

Primary Emergency Contact Last Name(s) *

Relationship to Minor *

Phone 1 *

Phone 2

Email 1 *

Email 2

Secondary Emergency Contact

Secondary Emergency Contact First Name *

Secondary Emergency Contact Last Name *

Relationship to Minor *

Phone 1 *

Phone 2

Email 1 *

Email 2

Health Conditions

This information will only be shared with medical professionals in the case of a medical emergency.

Medications

If your child is presently taking any medication, please indicate what type and why.

Drug Sensitivities

Please list any drug sensitivites.

Known Allergies

Please list any allergies.

Known Health Conditions

This information will only be shared with medical professionals in the case of a medical emergency. Although not required, feel free to list any pertinent health conditions your child has/had. (ie: asthma, heart condition, Covid-19, etc.)

Tetanus Shot

Date of your child’s last tetanus shot (if known).

Release

Parental Waiver & Indemnification

As the parent or legal guardian of the child named below, I hereby give my full consent and approval for my child to participate as a team member and individually in sand/beach volleyball at Third Coast Volleyball Club located at 5652 Forney Drive, Houston, Texas 77036.

I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as in traveling and other related activities incidental to my child’s participation, and I am willing to assume these risks on behalf of my child. I understand that these risks are significant and may include injury and illness (ex: communicable diseases such as MRSA, influenza, and COVID-19) and the potential for permanent disability and death.

I hereby certify that my child is fully capable of participating in the designated sport and that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in these activities, except as listed below.

In addition to giving my full consent for my child’s participation, I do HEREBY WAIVE, RELEASE AND HOLD HARMLESS Volleyball USA, Inc., Third Coast Volleyball; its directors, officers, officials, agents, employees, coaches, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and owners and lessors of premises, including Kimberlee A. De Marco and David V. De Marco, (“RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property incident to my child’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

Agreement to Parental Waiver & Indemnification *

I the above named Guardian has completely read and fully understand the “Parental Waiver & Indemnification” information (above), and I hereby, give consent to the terms.

YES, I agree.

Consent to Treatment of a Minor

The undersigned parent or guardian of the minor child named above, hereby authorizes Volleyball USA, Inc. dba Third Coast Volleyball Program Director, Trainers, Coaches, Staff, Agents, Owners and all certified medical doctors, Houston Fire Department (HFD) and Houston Emergency Medical Services (EMS) (“Authorized Agents”), to administer and render immediate medical attention as necessary, including authorizing Emergency Medical Services to provide immediate hospital care to said minor. The Undersign consents to allow for X-Ray examination, anesthetic, dental or surgical diagnosis and treatment be rendered to said minor by a licensed physician, whether such diagnosis or treatment is rendered at the office of said physician or dentist, in the emergency clinic, hospital or otherwise.

This authorization is given prior to any diagnosis or treatment known to be in order to enable said Authorized Agents to act effectively in an emergency situation where the undersigned cannot be contacted. Should said Authorized Agents exercise the consent hereunder upon the advice of a licensed physician or surgeon or dentist, I KNOWINGLY AND VOLUNTARILY RELEASE AND INDEMNIFY AND HOLD HARMLESS THE AUTHORIZED AGENTS ANY AND ALL AFFILIATES OF THE AUTHORIZED AGENTS FROM ANY & ALL LIABILITY FOR THIS ACTION.

I understand all reasonable measures will be taken to safeguard the health & safety of my child and that I will be notified as soon as possible in the case of an emergency or incident requiring medical attention.

The Medical Release authorization included herein, shall be active and remain in effect through December 31, 2024.

Agreement to Consent to Treatment of a Minor *

I the above named Guardian have completely read and fully understand the “Consent to Treat a Minor” information (above), and I hereby, give consent to Consent to Treatment the above named Child.

YES, I agree.

Notification Agreement to Update Information *

I agree to immediately notify Third Coast Juniors IN WRITING if any of the above information changes during the course of the current calendar year.

YES, I agree.

CONFIRMATION WILL BE SENT TO PRIMARY EMERGENCY EMAIL. (CHECK JUNK/SPAM!)

Signature of Parent or Guardian (Primary Emergency Contact) *

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