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Microsoft word - medical information & waiver forms.doc
Medical Information & Waiver Forms
This packet contains medical information forms and a sample waiver and release from liability form. In today's
climate of insurance claims and liability action, the use of these forms is mandatory by your club and/or league. Parent's Medical Instructions
This form can give your club coach or administrator instructions on how to proceed if an athlete becomes injured or
ill and needs emergency treatment. Medical History Questionnaire
If you are traveling and one of your athletes needs medical attention, this information can be of great value to an
The parent's Medical Instruction and the Medical History Questionnaire for each athlete should be kept in a sealed
envelope with his name on the outside in or with the club's medical kits. It is recommended that the kit also should
have a list of emergency phone numbers for each club member, along with the standard 911, police, ambulance,
fire, etc., phone numbers. Participant's Waiver and Release From Liability Form
This form provides the club administration a copy of a standard participant's waiver and release from liability form.
It is mandatory that club administrators have this form signed in addition to the form attached to the membership
card. Failure to obtain a waiver and release on members will result in a loss of insurance coverage.
Please keep medical forms for no less than 18 months. You must keep all Waiver and Release forms for 7 years.
PARENT'S INSTRUCTIONS ON MEDICAL TREATMENT
PLEASE PRINT IN CAPITAL LETTERS
Date of Birth
Please indicate another person to call it an accident occurs and we are unable to reach you:
Is your child presently on medication?
If yes, please list medication (s):
Date of your child's last complete physical examination by a medical doctor
If this is more than one year ago, please complete the accompanying medical history questionnaire.
Please read the alternative statements below and sign under the one that you choose. Sign only one!
1. If my child needs medical attention, it is my wish that I am contracted before any medical procedures are
taken on my child, unless immediate treatment is necessary to save my child's life or to prevent permanent
2. If my child needs medical treatment while participating, it is my wish that the treatment is started while
efforts are being made to contact me. So that treatment is not delayed, I consent to any medical
procedures that the physician believes are needed, on the understanding that efforts to contact me will
continue to be made. I accept responsibility for all costs related to such treatment.
Wrestler's USA Wrestling Card No.
Name of Club
MEDICAL HISTORY QUESTIONNAIRE
PLEASE PRINT IN CAPITAL LETTERS
USA Card No.:
PLEASE CIRCLE THE CORRECT ANSWER, ALL INFORMATION WILL BE CONFIDENTIAL
1. Are you allergic to any general medication (aspirin, sulfa, penicillin, etc.)? If so please
2. Are you now on any prescribed medication on a permanent or semi-permanent
basis? If so, please indicate the name of the medication and why it was prescribed
3. Have you ever had an epileptic seizure or been informed that you might have epilepsy?
4. Have you ever been treated for diabetes? If so, please indicate the type(s) of insulin or pills you use.
5. Has a medical doctor ever told you that you were anemic or had sickle cell anemia?
6. Do you have or have you ever had high blood pressure? If so, list any medication for it that you take
7. Do you have or have you ever had any of the following diseases? If so, please circle the appropriate
Heart disease (rheumatic fever) Liver disease (hepatitis)
Kidney disease (infections) Lung disease(pneumonia) Yes No
8. Have you ever been informed by a medical doctor that you have asthma? If so, what medications, if any,
9. Do you presently have an unrepaired hernia?
10. Have you ever been "knocked out" or experienced a concussion during the past 3 years? If so, give the
11. If the answer to No 10 is "yes" did the attending physician have you stay overnight in a hospital? If yes,
12. Have you ever had an injury to your neck involving nerves, vertebrae (bones),or discs that incapacitated
you for a week or longer? If yes, give the dates of each such injury.
13. Do you wear any dental appliance? If yes, circle the appropriate appliance:
PLEASE TURN THIS FORM OVER AND COMPLETE THE OTHER SIDE. THANK YOU.
14. Do you wear contact lenses during competition?
15. Have you had a fracture during the past 2 years? If yes, indicate which bone was broken and
16. Have you had a shoulder dislocation, separation or other shoulder injury in the past 2 years
that incapacitated you for a week or longer? If so, give the date of the injury.
17. Have you ever had surgery to correct a shoulder condition? If so, give the dates and what was done.
18. Have you ever had an injury to your back?
19. Do you experience Pain in your back? If yes, indicate frequency:
With vigorous exercise With heavy lifting
20. Have you injured your knee during the past 2 years with severe swelling as a result?
21. Have you ever been told that you injured the ligaments and / or cartilage of either knee?
22. Have you ever been advised to have surgery to correct a knee problem?
23. If the answer to No. 22 is yes, has the surgery been completed? Date
24. Have you experienced a severe sprain of either ankle during the past 2 years?
25. Have you had any injury to your foot or toes in the past 2 years. If yes, explain:
26. Do you have any chronic conditions that have not been mentioned above? If so, explain:
The questions on both sides of this form have been answered completely and truthfully to the best of my knowledge.
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
WITH PARENTAL CONSENT ("AGREEMENT")
IN CONSIDERATION of being permitted to participate in any way in any event ("Activity") at any time during the current calendar year I, for myself,
my personal representatives, assigns, heirs, and next of kin:
1. ACKNOWLEDGE, agree, and represent that I understand the nature of the Activity and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if, at any time, I believe the conditions to be unsafe, I will immediately discontinue further participation in the Activity.
2. FULLY UNDERSTAND that: (a) THIS ACTIVITY INVOLVES RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("Risks"); (b) these Risks and dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the Activity, the conditions in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISKS or SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time; and I FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES I incur as a result of my participation ,or that of the minor, in the Activity.
3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE the sanctioning organization(s), their administrators, directors, agents,
officers, members, volunteers, and employees, other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of Premises
on which the Activity is conducted, (each of the forgoing shall be considered one of the RELEASEES herein) FROM ALL LIABILITY, CLAIMS,
DEMANDS, LOSSES, OR DAMAGES ON MY ACCOUNT CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE
NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS; AND I FURTHER AGREE that if,
despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT I, or anyone on my behalf, makes a
claim against any of the Releasees, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES from any litigation expenses,
attorney fees, loss, liability, damage, or cost which may be incurred as the result of such claim.
I ACKNOWLEDGE THAT I AM OVER THE AGE OF 18 YEARS, HAVE READ THIS AGREEMENT AND FULLY UNDERSTAND ITS TERMS,
UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, HAVE SIGNED IT FREELY AND WITHOUT ANY
INDUCEMENT OR ASSURANCE OF ANY NATURE, AND I INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL
LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE
INVALID, THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Below section must be completed by Parent/Guardian for any participant under the age of 18.
AND I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE NATURE OF THE ACTIVITY AND THE
MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND
IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE,
COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE
RELEASEE'S FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR'S ACCOUNT
CAUSED, OR ALLEGED TO BE CAUSED, IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR
OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND FURTHER AGREE THAT IF, DESPITE THIS
RELEASE, I, THE MINOR, OR ANYONE ON THE MINOR'S BEHALF MAKES A CLAIMS AGAINST ANY OF THE
RELEASEES NAMED ABOVE, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM
ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR ANY COST THAT MAY OCCUR AS A
RESULT OF ANY SUCH CLAIM.
PARENT/GUARDIAN SIGNATURE (only if participant is under the age of 18):
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