ORU Junior Program Emergency Medical Release

Student Athlete’s Name__________________School_________Grade_______________

Date of Last Tetanus Booster____________________Birth Date____________________

Allergies (include food allergies)_____________________________________________

Special Conditions________________________________________________________

Medications Student Athlete is on  ___________________________________________

Medical Insurance Carrier__________________________________________________

Medical Insurance Number__________________________________________________

Student Athlete’s Physician_________________________Phone___________________

Emergency Contact (other than parent/guardian named below)

Name________________________Phone_______________Relationship_____________

In the event of an accident or injury to my child or in the event of illness of my child while in on or about the premises of Oregon Rowing Unlimited (ORU) or while participating in any activity sponsored by or under the auspices of said organization under circumstances where I am unable to consent or am not present.

I hereby authorize and consent to the administration of any and all medical, dental and surgical examinations or operations and treatment or all other related care, including the administration of drugs, tests, anesthesia and/or blood transfusions to my child that may be ordered by a physician and/or dentist in attendance at the medical center deemed necessary for emergency treatment.  I authorize any officer, employee or volunteer of ORU coaching, administrative or volunteer staff to consent to such medical care, attention or treatment.  I understand that ORU and its officers, employees and volunteers assume no financial obligation or liability in the case of my child’s accident, injury or illness.  I agree to pay the cost of such medical care, attention or treatment and to indemnify and hold harmless ORU, its officers, members, staff, volunteers and coaches or any other members thereof from any and all liability for such treatment, care or attention.

ORU will attempt to contact me before my child is treated but treatment will not be withheld if I cannot be reached. 

Signature of Parent or Guardian_____________________Date________Phone_______