Bluegrass Premier Field Hockey Club

Indoor Consent Form

Indoor Consent Form

 In order to enable appropriate and competent healthcare professionals and/or facilities to provide prompt medical care and treatment to your minor child in the event of an accident, injury, or illness occurring during participation in a Bluegrass Premier Field Hockey Club, LLC ("Bluegrass") sponsored, operated, or administered event or activity (an "Activity"), please supply the following information.

By submitting the form below, I certify that I am the parent or legal guardian and hereby give me permission for any staff member of Bluegrass, while acting in a supervisory capacity as to my Child and, in the event of, an accident, injury, or illness, to seek appropriate medical attention for my Child and authorize medical providers and/or facilities to provide medical attention to my Child. I agree I will be responsible for any and all costs related to the provision of the medical attention and treatment mentioned above and certify I have medical insurance to cover these costs.

I, as the parent or legal guardian of my Child (named below), understand and recognize the following:

  1. Field Hockey is a contact sport involving physical motion and activity often resulting in contact between players and other players and the sporting equipment necessary for playing field hockey;

  2. Such contact, as described in No. 1 above, can occur during the course of both instruction and competition;

  3. Such contact, as described in No. 1 above, may result in injury to my Child; and

  4. A number of minor children will be in attendance at any particular Activity and at each Activity there will be a limited number of Bluegrass coaches and supervisory personnel; as a result, no participant can receive constant and uninterrupted individual attention and supervision for the duration of any Activity.

In additional to the above I also do hereby acknowledge and represent the following:

  1. My Child is physically fit and mentally capable of participating in field hockey related Activities (“FH Activities”) and any component of any FH Activity or Activities in which my Child is involved; and

  2. I have sought the opinion of my Child’s physician and my Child’s physician concurs that my Child is fully capable of safely engaging in field hockey and any FH Activity in which my Child is involved, and

  3. I have provided my Child with the minimum necessary safety equipment for participation in field hockey and any FH Avctivity in which my Child is involved and which is specifically required of his/her playing position as mandated by the rules and regulations of U.S. Field Hockey.

By submitting the form below, I hereby give permission for my Child to participate in field hockey and FH Activities and do hereby release, waive, and discharge the Bluegrass, its staff, its members, and its administration from all rights and claims for damages arising from an accident, injury, or loss to person or property which may be sustained or occur during participation in a FH Activity.

Child's Name *
Child's Name
Date *
Date
Person to notify in case of emergency *
Person to notify in case of emergency
Phone Number *
Phone Number
Additional person to notify in case of emergency *
Additional person to notify in case of emergency
Phone Number *
Phone Number
Child's Physician *
Child's Physician
Physician Phone Number *
Physician Phone Number
Name of Policy Holder *
Name of Policy Holder