2015-16 Release Form
Athlete Name: _____________________________
T-Shirt Size: _______________________________
Athlete Cell:(_____) _________________________
Date of Birth:_______________________________
Address: _________________________________
Age as of August 31, 2015: ___________________
_________________________________________
City/State/Zip: _____________________________
Mother Name: _____________________________
Mother Cell: (______) _______________________
Father Name: ______________________________
Father Cell: (______) ________________________
Parent EMAIL (to send team placement and information emails: ______________________________
If new, WHO referred you to Fusion All-Stars?: ____________________________________________
Medical Authorization and Liability Release
EMERGENCY PROCEDURES: For minor injuries, Fusion All-Stars policy is to call the parent/guardian listed above,
and follow their directions. In the rare case of a more serious injury, Fusion All-Stars policy is to first call 911, then call
the parent/ guardian listed above.
EMERGENCY TREATMENT PRE-AUTHORIZATION: I authorize Fusion All-Stars and its representatives to consent to
medical treatment for my child when I cannot be reached to so consent. I also give Fusion All-Stars permission to
administer the necessary emergency care to my child to stabilize and/or improve the current injury or condition that my
child may have sustained during activities related to Fusion All-Stars instruction, practices, or performances. No prior
determination to life threatening emergency or danger of serious or permanent injury resulting from treatment need be
made under this authorization.
MINOR INJURIES / MEDICATION: Fusion All-Stars will provide bandages for minor scraps & cuts. We do not provide
medications.
SAF UH