<p>November 11, 2010</p><p>CONSENT FOR TREATMENT OF MINORS AND RELEASE OF LIABILITY </p><p>PLAYER:______LAST FIRST INITIAL DOB</p><p>FATHER/GUARDIAN:______</p><p>MOTHER/GUARDIAN:______LAST FIRST INITIAL PHONE</p><p>ADDRESS:______STREET ADDRESS CITY STATE ZIP</p><p>Person to notify in case of emergency (other than parent/guardian)</p><p>NAME:______RELATIONSHIP TO PLAYER:______</p><p>HOME PHONE:______WORK PHONE:______</p><p>ATHLETE’S PHYSICIAN:______PHONE:______</p><p>DENTIST:______PHONE:______</p><p>ALLERGIES (IF ANY):______</p><p>CURRENT MEDICATION (IF ANY):______</p><p>LAST TETANUS IMMUNIZATION:______</p><p>MEDICAL INSURANCE PROVIDER:______</p><p>GROUP OR POLICY #______</p><p>The undersigned, the parent(s) or legal guardian(s) of the above-named minor, hereby authorize my child’s coaches or any other official of the USA Elite Fastpitch to consent to any medical examination or treatment, including hospitalization and/or surgery, which is deemed advisable, </p><p>Page 1 of 2 November 11, 2010</p><p> appropriate or reasonably necessary by any physician, emergency medical technician, paramedic or other medical practitioner in order to properly care for my child in the event she sustains injury or is suffering from any illness during the course of any playing or non-playing activities with USA Elite Fastpitch provided, however, the foregoing consent or authorization shall be valid only in a situation where a parent or legal guardian of the above-mentioned minor is not reasonably available to provide consent for medical treatment.</p><p>I also give permission for my child to represent USA Elite Fastpitch, a softball organization, fielding competitive fastpitch teams and to accompany her team to any of its' local or out of town tournaments, games, practices or activities. In the event my child is injured or becomes ill during the course of any playing or non-playing activities with USA Elite Fastpitch, I hereby authorize her coaches or any other official of USA Elite Fastpitch to administer or obtain appropriate first aid and, if deemed reasonably necessary, to transport or allow for emergency transportation of my child to a physician, hospital or other health care facility for evaluation and treatment. </p><p>I hereby consent to my child’s participation in all USA Elite Fastpitch activities. I agree to release, indemnify and hold harmless USA Elite Fastpitch, including but not limited to its, coaches, officers, directors and agents, from and against any liability of any kind arising out of the activities of USA Elite Fastpitch or transportation related to such activities. </p><p>I understand that any medical insurance provided through ASA and/or USA Elite Fastpitch provides for excess or secondary coverage which will only apply after other insurance providing medical coverage for my child has been resorted to. I further understand that any coverage provided by ASA and/or USA Elite Fastpitch may have a deductible amount which I/we as the parent(s) and/ or Guardian(s) of the above-mentioned minor will be responsible for paying.</p><p>The Undersigned understand that participation in competitive fastpitch softball as an athletic endeavor involves risks of physical injury or death which cannot be totally eliminated. However, players may reduce such risk by following a proper conditioning program, wearing or using helmets and other appropriate safety equipment, and properly reporting any injury to their coaches. In allowing my child to participate in the activities of USA Elite Fastpitch , the undersigned understand and acknowledge that we are expressly assuming the risks of participation on behalf of the above-mentioned minor and hereby release USA Elite Fastpitch, including but not limited to its' coaches, officers, directors and agents from any and all liability arising out of or in any way related to the activities giving rise to such risks. </p><p>Signature of Father/Guardian(s):______Date:______</p><p>Signature of Mother/Guardian(s):______Date:______</p><p>Signature of Player:______Date:______</p><p>E-mail Addresses:______</p><p>Cell Phone Numbers:______</p><p>Page 2 of 2 </p>