Urban Impact Middle School Basketball League

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2020 Middle School League Player Registration & Medical Release Form

STUDENT INFORMATION

* First Name:

Middle Initial:

* Last Name:

* Grade:

* Birthdate:

Gender:

* Street:

* City:

State:

* Zip Code:

Primary Phone:

Primary Phone Type:

Student Cell Phone:

May we text this phone?:

* Team/Organization:

* School:

* Student attends church?:

Church attended (if applicable):

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* Relationship to Player:

* Primary Phone:

Primary Phone Type:

Alternate Phone:

Alternate Phone Type:

Email:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Relationship to Player:

Primary Phone:

Primary Phone Type:

Alternate Phone:

Alternate Phone Type:

Email:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact (if Parent/Guardians cannot be reached):

* Relationship to Player:

* Primary Phone:

Allergies, Health Concerns, Activity Restrictions (List all that apply):

* Insurance Carrier:

Policy #:

Primary Care Physician (if applicable):

WAIVER INFORMATION

EMERGENCY MEDICAL AND LIABILITY RELEASE

By checking the box below I am indicating that in the event of an emergency and in the event that: (1) a parent/legal guardian or the Authorized/Designated Individual identified above cannot be reached; or (2) immediate medical attention is necessary, I consent to have Urban Impact Foundation [UIF] staff/leaders/volunteers act in my behalf and hereby grant my permission for emergency treatment to be administered until a parent/legal guardian or the Authorized/Designated Individual identified above can be reached. I am consenting to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to his authorization. I agree not to hold Urban Impact Foundation, The Pittsburgh Public Schools, Allegheny Center Alliance Church, organizations partnering with Urban Impact, or any staff/leaders/volunteers liable for any decisions for any emergency medical treatment made under this authorization or for any accident or loss to the student however caused.
In addition, I do hereby release, forever discharge and agree to hold harmless Urban Impact Foundation, The Pittsburgh Public Schools, Allegheny Center Alliance Church, partnering organizations and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described trip or activity.

PERMISSION TO TRANSPORT

I give UIF permission to transport my son/daughter to and from UIF programs and UIF related events.

PROMOTIONAL RELEASE

I also release UIF to use photos, video and audio of my student in promotional materials that support Urban Impact Foundation & its programs. I understand photos may be used on billboards, bus stop advertisements, and online social media like Facebook. I release UIF from any liability connected with the use of my picture or voice recording as part of any promotional recruitment or fundraising program.

As the parent/legal guardian(s) of this participant, I/we agree with the above *

* indicates required fields

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2020 Middle School League Player Registration & Medical Release Form