Wichita angels

Angels Academy
2012-13 Release & Medical Form Child Name ________________ Age ___ Grade ___ Shirt Size YS YM YL AS AM AL XL XXL Child Name ________________ Age ___ Grade ___ Shirt Size YS YM YL AS AM AL XL XXL Child Name ________________ Age ___ Grade ___ Shirt Size YS YM YL AS AM AL XL XXL Parents Names ______________________ Home Phone _______________ Cell # ______________________ Family Email _____________________________ 2nd Email _______________________________________ Address _______________________________________________ City ____________ Zip Code __________ Sport or Activity you are signing up for: ________________________________________________________ Person to contact in Emergency _________________________ Emergency Contact # ___________________ Doctor______________________________________________ Hospital _____________________________ Insurance Company __________________________________ Insurance # ___________________________ Do any of your children have allergies? If so, what? _____________________________________________ __________________________________________________________________________________________ Are any of your children on medications which may affect their balance, coordination, breathing, or heart rate (such as: benadryl or antihistamines, Zoloft, Prozac, Sarafem, Xanax, Uniphyl or asthma medication, Sudafed, Triaminic, or other cold medicine, Micronase, Prandin, Insulin, etc.) Please list medications below: __________________________________________________________________________________________ Comments: ______________________________________________________________________________ Release Statement
I, the undersigned, to induce the Wichita Angels (WA) and Angels Academy (AA) and any or all instructors conducting practices/activities, hereby give my consent and agree to release, indemnify, and hold harmless AA & WA from all damages for any claim arising out of any injury, physical or mental, to or loss of life by any participant, in any way related to any participants presence at or participation in AA & WA facilities or activities, including, without limitation any complications to such injuries caused/aggravated by any participants pre-injury state of health or refusal to obtain medical treatment based on any personal beliefs or otherwise. Furthermore, I hereby authorize personnel associated with AA & WA, as my agents, to take actions, to consent to medical/surgical exams/treatment as may be required in emergencies to preserve the physical well-being of any participant; provided prudent efforts have been made to contact any listed legal guardian to notify the same of the situation. I also consent to allow pictures or video of my child’s classes to be used in media promotions for Angels Academy and the Wichita Angels. Standards of Conduct
“This is my commandment, That you love one another as I have loved you.” “Honor all people. Love the brotherhood. Fear God. Honor the king.” “Do all things without complaining and disputing.” “…adorn themselves in modest apparel…” By signing below, I acknowledge that I have read and understand the above Release Statement and Standards of Conduct.
Fathers Name ______________________________ Mothers Name __________________________________ Fathers Signature ___________________________ Mothers Signature ________________________________ Date _____________________________________ Date ___________________________________________ **Please be sure and E-mail this form t(Dave Yordy)**

Source: http://wichitaangels.com/wordpress/wp-content/uploads/2013/02/2012-13+Release+Statement.pdf

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