Medical Waiver Form

Metro St. Louis Basketball League

Mr. Lou Potsou - Director

Circle Grade Level 2^nd 3^rd 4^th 5^th 6^th 7^th 8^th 9^th 10^th 11^th 12^th

Check One Boy ( ) Girl ( )

First Name _________________________Last Name______________________________________

Address __________________________________________________________________________

City _________________________________________State _____________Zip Code ____________

Home Phone ______________________________ Work Phone _____________________________

Cell Phone ________________________E-Mail Address ____________________________________

Coaches Name _________________________ Team Name ______________________________

Waiver:

In Consideration of your acceptance of my participation in the Metro St. Louis Basketball League (MSTLBL), I the undersigned player will follow the rules of the MSTLBL; obey my coach/team leader, officials and directors. I have had a physical examination in the past year and have been found fit for all physical endeavors.

I/ we, the undersigned, herby authorize any first aid, medication, medical treatment or surgery deemed necessary in case of an emergency for the undersigned player, a participant in the MSTLBL program.

I/ we, the undersigned, in consideration of the undersigned player’s participation in the MSTLBL program, intending to be legally bound, do hereby for ourselves, executors, and administrators waive, release, and forever discharge any and all rights and claims for damages, including any claims for loss, damages or injury to our persons or property arising out of the undersigned players performance or failure of performance from the MSTLBL program, the executive board of the MSTLBL or the facilities for which we are participating.

I/ we, the undersigned, agree to hold harmless, indemnify, and defend Facility Owner or Operator from any and all liability which may result from any person using the facilities, its entrances and exits, and surrounding areas.

________________________________________ __________________________________

Player’s Signature Parent/Guardian Signature

________________________________________ __________________________________

Date Date

Please make one copy per player of the Medical Waiver Form. This form must be signed by parent and player before he/she is allowed to play in the MSTLBL. One copy of waiver should be give to the site coordinator and another kept by the coach at all times. This form is required before the first game.