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Upskate NY JRD Medical Treatment Release

Upskate NY JRD
Medical Treatment Release

I, grant permission to managing personnel and league
representatives of Upskate New York Junior Roller Derby (UNYJRD) to authorize and obtain medical care
from any licensed physician, hospital or medical clinic, should
, for whom I am parent/guardian become ill or injured while
participating in league activities and am unable to grant authorization for immediate treatment. I assume all
risks and hazards incidental to such participation, including transportation to and from league activities, and
do hereby waive, release, indemnify and agree to hold harmless UNYJRD and any UNYJRD agents, assigns,
representatives, officers, and employees from any and all claims arising out of my participation in any and all
league activities.
Please list below any medical information or conditions, which may be relevant to your care and treatment
(emergency or otherwise).

Leave this empty:

Your legal name

Your email address

Please Confirm full name and signature.

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September 15, 2023 4:43 pm EST

Upskate NY JRD Medical Treatment Release Uploaded by Holly White - upskatenyjrd@gmail.com IP 208.117.114.126