A.S.K. Lituanica

MEDICAL  RELEASE of

(Print Name of Child)  ____________________________________

                                   Born on: _______________,19 ________

(Home Address)          ____________________________________

                                   ___________________________________

 (Home Phone Number)      _________________________________

(Additional Phone Number and Contact Person in case of  emergency)_______________________________________________

Please list any medical conditions which may require special attention:

__________________________________________________________

__________________________________________________________

__________________________________________________________

Child's physician's name and phone number:______________________

__________________________________________________________

Parents' Insurance coverage:  Name_____________________________

       Id. No._________________________

                                                                                                         A.S.K. Lituanica

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY

I hereby release A.S.K. Lituanica staff to render temporary first aid to me, my child or children in the event of any injury or illness, and if deemed necessary by A.S.K. Lituanica staff to call our doctor and to seek medical help including transportation by A.S.K. Lituanica  staff member to any health care facility or hospital or the calling of an ambulance if A.S.K. Lituanica deem this to be necessary.
We, the staff recognize our obligation to make our students and their parents aware of the risks and hazards associated with the sport of basketball.  Students may suffer injuries, possibly minor, serious or catastrophic in nature.  Basketball may be dangerous and can lead to injury.
Parents should make their children aware of the possibility of injury and encourage their children to follow all safety rules and instructions from coaches.
A.S.K. Lituanica, it's coaches and other staff members, will NOT accept responsibility for injuries sustained by any participant during the course of any instructional classes, team work-outs, or open work-outs, or in the course of any exhibition, competition or clinic in which he or she may participate or while traveling to or  from an event.
With the above in mind, and being fully aware of the risks and possibility of injury involved, I consent to have me, my child or children participate in the programs offered by A.S.K. Lituanica.  I, my executors or other representatives, waive and release all rights and claims for damages that I my child may have against A.S.K. Lituanica and /or its representatives whether paid or volunteer. 
I also affirm that I now have and will continue to provide proper hospitalization, health and accident insurance coverage which I consider adequate for both my child's protection and my own protection.
I also understand that it is the parents' responsibility to warn the child about the dangers of  basketball and injury.  The parent should warn the child according to what the parent feels is appropriate.  A.S.K. Lituanica will only warn the child through "safety messages" and our teaching style and proper progressions.
This acknowledgment of risk and waiver of liability, having been read thoroughly and  understood completely, is signed voluntarily as to it's content and intent.

Parent/Guardian signature_______________________Date____________   

Applicant's signature____________________________Date___________