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Alameda Vipers Medical Release 2014-15

Player Medical Release Form to be completed by Parent or Guardian.
I hereby give permission for any and all medical attention necessary to be administered to my child. In the event of accident, injury, sickness, etc., while they are
under the care and supervision of the Alameda Vipers AAU Basketball Club until such time as I may be contacted and/or
present at the event. I have also authorized alternate persons to be contacted for guidance. I hereby give permission for treatment of my child as may be required and determined by the appropriate health care professional who is present.
This release remains in effect annually for the duration of my child’s membership with Alameda Vipers. I hereby assume responsibility for payment of such treatment and have attached my child’s insurance information.

Head Coach *
Head Coach
Phone *

In case I cannot be reached, either of the following is designated an alternative contact person:
ALT Contact1 Name
ALT Contact1 Name

ALT Contact1 Phone
ALT Contact1 Phone
ALT Contact2 Name
ALT Contact2 Name

ALT Contact2 Phone
ALT Contact2 Phone
Child Medical Information

Physician’s Name *
Physician’s Name
Physician’s Phone *
Physician’s Phone

Terms and Conditions *
Have you read and agree with our Player Terms and Conditions?

This document includes: Release and Waiver of Liability and Indemnity Agreement, Medical Release Information, General Information, Alameda Vipers Code of Conduct, Player Code of Conduct, Parent/Guardian Code of Conduct, Parent/Guardian Commitment and Photo Release.

To verify all the information above is correct and that you have read and agree with our terms and conditions, please type your full name.

Date *