Membership waiver (photo clause)

MEDICAL AUTHORIZATION AND INFORMATION
I/We do hereby authorize Sylvia Soto, Tim Hoffman, Kurt Dulka, Francis Mariner, Drew Reimers, Jon
DiMauro, Chris Davis, Tim FitzGerald, Daniel Benjamin, Ian Williams, OR Michael Ireland, individually, as
AGENTS for the PLAYER named below. At our (parents’ and player’s) sole expense, any AGENT may
consent on behalf of PLAYER to any X-ray examination, anesthesia, medical or surgical diagnosis or treatment,
or hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of,
any physician or surgeon licensed under the laws of the location where treatment is rendered; or any X-ray
examination, anesthesia, dental or surgical diagnosis or treatment, or hospital care which is deemed advisable
by, and is to be rendered under the general or special supervision of, any dentist licensed under the laws of the
location where treatment is rendered.
This authorization is given in advance of any specific diagnosis, treatment, or hospital care to provide authority
and power on the part of any AGENT to give specific consent to any and all such diagnosis, treatment, or care
which aforementioned physician, surgeon, or dentist, in the exercise of his/her best judgment, may deem
advisable. This authorization is given pursuant to the provisions of California Family Code §6910.
I/We authorize AGENTS to provide PLAYER with any “over the counter” medicines (e.g., aspirin, Tylenol
(acetaminophen), Advil (ibuprofen), Claritin (allergy), vitamins, minerals, salts, etc.) for self-administration.
I/We do hereby authorize AGENTS to provide to PLAYER first aid and to evaluate, treat, and rehabilitate
existing or new injuries to PLAYER, which may include stretching, taping, icing, warming, massage, cleaning
and bandaging cuts and abrasions, applying topical treatments (e.g., Neosporin, hydrogen peroxide,
hydrocortisone, iodine, Bactine, Tiger Balm, etc.) or referring PLAYER to other medical or dental
professionals.
These authorizations shall remain effective FOR ONE YEAR FROM THE DATE BELOW. The medical
information provided below is accurate and complete to the best of my/our knowledge and may be shared
among AGENTS, Orca Rugby coaches, and with medical professionals assisting PLAYER.
I/WE ACKNOWLEDGE THAT ORCA RUGBY STRONGLY RECOMMENDS EVERY PLAYER
UNDERGO AN ANNUAL THOROUGH PHYSICAL EXAMINATION BY A LICENSED MEDICAL
PROFESSIONAL TO ENSURE THE PLAYER IS FULLY CAPABLE OF PARTICIPATING IN THE
PUNISHING AND SEVERELY DEMANDING SPORT OF FULL CONTACT RUGBY.

PLAYER’s Name (print)
If PLAYER is under the age of 18, a parent or legal guardian must sign: I have legal authority to consent to medical treatment of the minor PLAYER named above. I hereby authorize and consent to medical and dental treatment of the minor PLAYER as stated above. I hereby authorize any medical facility which has provided treatment to the minor PLAYER to surrender physical custody of PLAYER to any AGENT upon completion of treatment pursuant to California Health and Safety Code §1283. I further authorize AGENTS to provide to the minor PLAYER first aid and evaluation, treatment and rehabilitation of existing or new injuries as stated above. I guarantee payment of all expenses incurred for minor PLAYER for emergency transportation and/or treatment by licensed medical and dental professionals as described above. Minor PLAYER’s Parent/Guardian Name (print) ATTACH COPY OF BOTH SIDES OF INSURANCE CARD
MEDIA WAIVER

I/We do hereby authorize and give my/our full consent to Orca Rugby, SCYR, or SCRFU (collectively, the
“Publishers”) to copyright and/or publish any and all photographs, images, videotapes, film, web
casts/podcasts, and any other form of visual/audio communications in which I appear while attending any
rugby-related events (as a player or otherwise). To publicize, document, and assist the media in reporting rugby
events or to publicize or promote rugby, the Publishers may publish (print, electronic, or online) photographs of
me, my name, my home town, my school, my club affiliations, personal statistics (age, jersey #, position,
CIPP#, etc.), or other biographical and personally identifiable player information in any form including a media
guide or press release. I further agree the Publishers may transfer, use, or cause to be used, these
communications and publications for any exhibitions, public displays, publications, commercials, art and
advertising purposes, and television programs without limitations or reservations and without compensation to
me.
The Publishers will not distribute my telephone number, home address, or email address to anyone except the
Publishers and staff and players in my club, and to agencies (park districts, cities, funding entities, USA Rugby,
etc.) as required to obtain permits, insurance, or other authorizations needed to conduct or fund rugby activities.
PLAYER’s Name (print)
If under the age of 18, a parent or legal guardian must sign. I have legal authority to consent to the release of information concerning the minor PLAYER named above. I hereby authorize and consent to Publishers’ use and release of information concerning the minor PLAYER as described in detail above. Minor PLAYER’s Parent/Guardian Name (print) PLAYER MEDICAL INFORMATION DATED:
Player’s FULL Name
Check all that apply to PLAYER NOW:
hemophilia hearing aid dental appliance (retainer) contact lenses Check all that apply to PLAYER in the LAST YEAR and explain briefly:
hospitalized
fractured/broken/dislocated bone cast/splint List ALL known allergies (examples: soy, peanuts, penicillin, bees, latex, etc.):
List ALL medicines, vitamins/herbs, prescriptions currently taken (examples: Hydroxycut, Centrum vitamin,
ginseng, birth control, creatine, etc.):
Date of last immunizations (mm/yr): (recent Tetanus highly recommended)
Diptheria, Pertussis, Tetanus (DPT)

Source: http://orcayouthrugby.org/wp-content/uploads/2011/09/OrcaRugbyRegistrationForms.pdf