1. sports
2. bobsled

Liquid Ninja Run Club Emergency Medical Authorization and Contact Information Form Runner Name: __________________________ Birth Date: ___/___/_____
Address: ________________________ City: _________________
Grade: ______
Zip Code: ________
Contact Phone Number: (____)____________________
PARENT/GUARDIAN AND EMERGENCY CONTACTS
Call
Order:
1
2
3
4
5
Relationship:
Name:
Contact Phone Number(s):
MEDICAL/INSURANCE INFORMATION
Physician’s name_________________________ Location______________ Phone:__________
Insurance Provider: _______________________________
Group/Plan: _________
Please indicate if your runner has any of the following:
Allergies (please list):
_____________________________________________________________________________
Medications (please list):
____________________________________________________________________________
Other Medical concerns or conditions to which medical personnel should be alerted (please list):
______________________________________________________________________________
______________________________________________________________________________
PART I CONSENT FOR EMERGENCY MEDICAL ATTENTION
(Part I or Part II muse be completed and signed)
I approve my child’s participation in the Liquid Ninja Run Club and hereby authorize the coaches
to act for me according to their best judgment in any emergency requiring medical attention. I am
aware that during sports participation certain activities may require strenuous physical exertion,
which could result in physical injury. I know of no physical condition (chronic illness, injury) that
would prevent my child from participation. I will be responsible for any medical or other charges
in connection with his/her activity participation.
_____________________________________
Parent signature
___________
Date
PART II: REFUSAL TO CONSENT
I do NOT give consent for emergency medical treatment of my child. In the event of illness or
injury requiring emergency treatment, I wish for the following action(s) to be taken:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
_____________________________________
Signature of Parent/Guardian for Refusal to Consent
(see back of page for additional required information) ___________
Date
Liquid Ninja Run Club Membership Waiver of Participation
As a participant in the Liquid Ninja Run Club, I know that running in and other activities
and volunteering for organized group runs, social events, and races with this club are
potentially hazardous activities, which could cause injury or death. I will not participate
in any club organized events, group training runs or social events, unless I am medically
able and properly trained, and by my signature, I certify that I am medically able to
perform all activities associated with the club and am in good health, and I am properly
trained.
I agree to abide by all rules established by the club, including the right of any official to
deny or suspend my participation for any reason whatsoever. I assume all risks
associated with being a participant of this club and participating in club activities which
may include risks such as falls, contact with other participants, the effects of the weather,
including high heat and/or humidity, traffic and the conditions of the road and all such
risks being known and appreciated by me.
Having read this waiver and knowing these facts and in consideration of your accepting
my participation, I, for myself and anyone entitled to act on my behalf, waive and release
the Liquid Ninja Run Club, all club sponsors, their representatives and successors from
all claims or liabilities of any kind arising out of my participation with the club, even
though that liability may arise out of negligence or carelessness on the part of the persons
named in this waiver.
Runner’s Signature: _____________________________
Date: ___________
Parent’s Signature: ______________________________
Date: ___________
(if under 18 years of age)
(see back of page for additional required information)