| Illinois Renegades Basketball & Training Parental Consent, Certification & Medical Authorization Form Parents and legal guardian of minor children are asked to complete and return this form. Thie information requested is designed to assist in providing for the safety of minors participating in Illinois Renegades Basketball & Training club teams, practices, tournament schedule and personal training. GENERAL INFORMATION: Child’s Name: _______________________________ Date of Birth: ___________________ Father’s Name: _______________________ Mother’s Name: _______________________ Address: _______________________________________________________________________ Home Phone#: ______________________ Parent’s Work Phone #: _______________________ Cell Phone #(1) :________________________ Cell Phone # (2): __________________________ Family Doctor: _________________________ Phone#:______________________________ Address: _________________________________________________________________ CONSENT & CERTIFICATION I, the undersigned, being the parent or legal guardian of the child named above (the Child), do hereby consent to the participation of my child in Illinois Renegades Basketball & Training Club teams for practices, tournaments, and personal training. MEDICAL TREATMENT AUTHORIZATION I understand that I will be notified in the case of a medical emergency involving my child. However, in the event I cannot be reached, I authorize the calling of a doctor and the providing of necessary medical services in the event my child is injured or becomes ill. I understand that Illinois Renegades basketball & training will not be responsible for medical expenses incurred, but that such expenses will be my responsibility as parent/guardian. I agree to notify Illinois Renegades Basketball & Training of any health changes which would restrict my child’s participation. I also understand that the adult supervision reserve the right to restrict my child from participation if they do not feel my child is within the physical capabilities. A photocopy of this document has the same force and effect as the original. ________________________________ _____________ Signature of Parent/Guardian Date ____________________________ Claim# ___________________ Medical Insurance Company Group ____________________________ Name of Insured ________________________ Illinois Renegades Basketball & Training – 708 Riedy Rd – Lisle IL 60532 – (p) 630-649-3641 www.illinoisrenegadesbasketball.com |
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| Illinois Renegades Basketball & Training Parental Consent, Certification & Medical Authorization Form 1. Has your child ever been hospitalized? (For what? / When?)_____________________________ 2. Has your child ever had surgery? (Type? / When? ) __________________________________________________________________________ 3. Is your child currently taking Medication, including asthma medication? __________________________________________________________________________ 4. Circle any conditions that are applicable to your child and explain: • Has your child ever passes out during exercise?_________________________ • Has your child ever been dizzy during exercise? _________________________ • Has your child ever had chest pains? _________________________________ • Does your child tire more quickly than others during exercise? _____________ • Has your child ever had high blood pressure?___________________________ • Has your child ever had a racing heart or skipped beats? __________________ • Has your child ever had heat cramps? ________________________________ • Has your child ever been dizzy or passed out in the heat? _________________ 5. Has anyone in your family died of heart problems or a sudden death before the age of 40? __________________________________________________________________________ 6. Has your child ever had a head injury, concussion? (Date?) __________________________ *Has your child ever been knocked out? (Date?) ___________________________________ *Has your child ever had a stinger, burner, or pinched nerve? (Date) ___________________ 7. Has your child ever sustained an injury to the following? Please circle. L/R Hand L/R Neck L/R Back L/R Ankle L/R Wrist L/R Chest L/R Elbow L/R Hip L/R Forearm L/R Thigh L/R Arm L/R Shin L/R Knee L/R Foot L/R Calf L/R Shoulder 8. Does your child use special pads/braces? (List & Explain) ___________________________ __________________________________________________________________________ 9. Is your child presently being treated for an injury or sickness? ________________________ __________________________________________________________________________ 10. Is your child allergic to any type of medication? __________________________________ 11. Does your child have (or has ever had) the following? Seizure disorders Hay Fever Hepatitis Asthma Kidney Disease Stomach Ulcer Heath Murmur Headaches (freq/severe) Diabetes Mononucleosis Arthritis Sickle Cell Anemia Tuberculosis Eye Injuries Ear problems 12. Is there any medical condition your child has had or has that is not listed on this medical form? ___________________________________________________________________________ Illinois Renegades Basketball & Training ~ 708 Reidy Rd ~ Lisle. IL 60532 ~ 630-649-3641 ~ www.illinoisrenegadesbasketball.com |