I certify that I am the parent or legal guardian of the above mentioned Participant. I hereby authorize my minor child named above to attend and participate in the DERBY CITY ATHLETIC CLUB (DCAC) events, including practices and club meets. I understand that my minor child must obey all established rules and follow the instructions of the person in charge of the DCAC. Prior to the participation of my minor child, I acknowledge that there are certain risks associated with certain DCAC activities, including, by way of example, physical injury due to activity-related accidents. Furthermore, In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware. Accordingly, I acknowledge that participation in such activities involves certain dangers and risks which may expose my child to hazards of bodily injury or property damage. I also expressly assume all risks to my child’s participation in these DCAC, whether such risks are known or unknown to me at this time. In recognition of these risks and realities, and in consideration of my child being offered the opportunity to participate in and benefit from DCAC activities, I agree on behalf of myself and my child to release, waive, and disclaim any and all liabilities of or claims against, DCAC, its officers, agents, and all private persons or organizations Volunteering services without charge to transport, supervise, or chaperone my child while participating in such DCAC activities including, but not limited to any or all liabilities or claims for personal injury, property damage, court costs, attorneys’ fees and interest, however, caused or accrued, as a result of my child participating in the DCAC - sponsored event.
MEDIA RELEASE I hereby give DCAC and their legal representatives and assigns, the right and permission to photograph, digitally record, videotape, or audio tape, my above named child while s/he is attending participating in any DCAC events. I further agree that any or all of the material recorded may be used, in any form, in publications, including electronic publications, or in audio-visual presentations, promotional literature, advertising, or in other similar ways, and that such use shall be without payment of fees, royalties, special credit, or other compensation. I understand that all such recordings, in whatever medium, shall remain the property of DCAC.
MEDICAL AUTHORIZATION / CONSENT FOR MEDICAL TREATMENT OF A MINOR I recognize that there may be occasions where the minor child named above, may be in need of first aid or emergency medical or dental treatment as a result of an accident, illness, or other health condition or injury. Therefore, I authorize any DCAC Coach, Representative, or Adult Volunteer, in whose care the minor child has been entrusted, to consent to any X-ray, examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor by the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. In so doing, I agree to pay all fees and costs arising from this action to obtain medical treatment. As parent or legal guardian of my minor child (Participant named above), I am responsible for the health care decisions of my minor child and am authorized to consent to the services to be rendered. I represent that my consent to and agreement to pay for dental, medical, and/or hospital care or treatment to be rendered to my minor child is legally sufficient and that no consent from any other person is required. By signing below I authorize any DCAC Coach, Representative or Adult Volunteer, in whose care the minor child has been entrusted to authorize any hospital or physician or other health care provider to bill the insurance company or companies for the payment of any services rendered to the minor child. I agree to assume responsibility for the charges for such care as rendered to the above named minor child. I authorize any hospital, physician, or other health care provider to release information from the minor child's medical record to the insurance company, in connection with the completion of any insurance claim form. I have read, understood and agreed to the information above.
All releases, authorizations and permission granted above shall remain in effect unless revoked in writing by the undersigned to Derby City Athletic Club, 300 Pepperbush Rd., Louisville, KY 40207.