Coach Rudi Sports Academy

Providing the best sports activities for youth in San Francisco, California.

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Download the CRSA Medical Waiver Form Here

*Waiver is valid for one complete school year.

Coach Rudi Sports Academy

YOUTH PARTICIPANT MEDICAL INFORMATION & RELEASE

The following waiver and release form must be completed for participants in Youth camps, sports and recreation programs

I hereby give permission to the medical personnel selected by CRSA and it's adult staff to arrange for emergency medical treatment, order x-rays, routine tests, to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for my child. In the event I am unable to make decisions in an emergency, I hereby give permission to the physician selected by CRSA and its adult staff to secure and administer treatment, including hospitalization, for the child named below.
I authorize approved staff members to transport my child in personal vehicles in case of events or emergencies

* Required

Child Full Name * Date of Birth *

Primary Address *

Email Address * Zipcode*

Parent Full Name Work Phone *

Home Phone* Cell Phone*

Emergency Contact (other than parent)

Relationship Home Phone

Work Phone Cell Phone

Physician's Name Physician's Phone

Health Insurance Company Group Policy

Name of Policyholder

Insurance Company Phone

Please list all allergies, including medicines, foods, insects

Is your child currently taking medicine for an existing medical condition (i.e., asthma medication)
Yes
No

If Yes, please list

YOUTH PARTICIPANT WAIVER AND RELEASE OF LIABILITY

In consideration of my child, named above, being allowed to participate in camps, sports and recreation programs at Coach Rudi Sports Academy, San Francisco, CA (CRSA), the undersigned acknowledges and agrees that:

Participation in camps, sports and/or recreational activities can result in physical injuries. While particular rules, equipment and personal discipline may reduce such risks, the risk of injury, including serious injury and disability, does exist.

The undersigned, knowingly and freely assumes all such risks, both known and unknown, and assumes full responsibility for the participation of the minor child noted above.

The undersigned, on his or her behalf, on behalf of the child noted above, and behalf of all heirs, assigns, personal representatives, and next of kin, hereby releases and holds harmless, to the extent permitted by law, CRSA, its officers, officials, agents and/or employees, its sponsors, and other participants and their families with respect to any and all injury, disability, death, loss, or damages to person or property

The above waiver and release forms are valid for the current school year 2012-2013.

I have read this release of liability and assumption of risk agreement fully understand its terms and by submitting this form I am agreeing to it freely and without any inducement.
Yes
No

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