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2017 Medical Consent Form

 

Dan Duquette Sports Academy P.O. Box 2021 Hinsdale MA 01235 Phone: 413-655-8077 FAX: 413-655-8653

CONSENT FOR MEDICAL TREATMENT OF A MINOR

____________________________________ Print Camper’s Name

As Parent or legal guardian of the above-named person, I hereby give permission to the medical personnel selected by the camp director to provide routine health care; to administer medications; to order X-rays, routine tests, treatment; to release any records necessary for insurance purposes; and to provide or arrange necessary related transportation for me/or my child. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the camp director to secure and administer treatment, including hospitalization, for the person named above.

Should the need arise for urgent medical care for my child, Dan Duquette Sports Academy may refer my child to the Suburban Internal Medicine office for medical care. Services provided by Suburban Internal Medicine may or may not be covered by my health insurance. In the event that these services are not covered by my insurance, Suburban Internal Medicine reserves the right to bill me directly.

I hereby give permission to the Berkshire Medical Center emergency department staff to begin evaluation and treatment to the person named above until such time I can be contacted. I hereby give permission to the emergency department staff of an appropriate hospital chosen by the camp staff to begin evaluation and treatment to the person named above until such time I can be contacted in the event that an emergency occurs while at an off-site event or during transit to or from an off-site event. This completed form may be photocopied for trips out of camp.

_______________________________

Signature of Parent/Guardian

_______________________________ _______________________________

Relationship to Camper Date

This consent form covers any session during the 2017 season 

Accident Release Form

 

DAN DUQUETTE SPORTS ACADEMY
ACCIDENT WAIVER AND RELEASE OF LIABILITY
FOR ADULTS AND COACHES

By enrolling the in the Dan Duquette Sports Academy, I represent and ensure that I am at least eighteen (18) years of age, and that I am physically and mentally able to participate in all of the Academy’s activities and have been examined by a licensed medical physician within one (1) year prior to attending the Academy. I understand that the Dan Duquette Sports Academy, DDD Baseball, LLC, The DDD Nominee Trust, their shareholders, members, directors, officers, trustees, employees, volunteers, advisors, representatives, independent contractors, agents, assigns, and the property on which the Academy is located cannot be held responsible in whole or in part for any accidents, illness or injuries resulting in medical or dental expenses incurred by me from participation in any of the Academy’s programs or activities. I hereby release each of the above named parties from and against any and all claims, costs, liabilities and injuries incurred by me while at the Academy, or while participating in any activities of or related to the Academy. I agree to assume full and complete responsibility for any and all medical bills arising from my participation in the activities of the Academy, and hereby agree to indemnify and hold the aforementioned parties harmless from any and all liability associated with my participation at the Academy or in Academy functions, including all costs and fees incurred by the aforementioned parties.

By signing this Wavier and Release agreement, I acknowledge that I HAVE READ AND FULLY UNDERSTAND AND AGREE TO ALL OF ITS TERMS AND CONDITIONS, INCLUDING THE PERMISSION TO TREAT AGREEMENT AND OTHER RELATED DOCUMENTS PRESENTED TO ME BY THE DAN DUQUETTE SPORTS ACADEMY PRIOR TO ENGAGING IN ANY ACTIVITIES AT THE ACADEMY. I further state that I have executed this waiver and release voluntarily and with full knowledge of its significance to be binding on me, my heirs, executors, administrators and assigns.

I hereby accept the terms above stated:

______________________________________ Signature

______________________________________ Print Name

_____________________________________________ Date