Buckeyes Baseball Club and Travel Baseball Consent Form • Baseball Heritage Museum

PLAYER INFORMATION

Player's Name *

First

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Player's Email(s)

List all.

Player's Date of Birth

Player's Cell Phone

Player's Current Age

High School

High School Graduation Year

Date Phone Tshirt

Positions

Throws

Bats

Height

Weight

Tshirt Size

Shorts size

EMERGENCY CONTACT INFORMATION

Guardian 1

First and Last Names

Relationship

Cell Phone

Email

Home Phone

Guardian 2

First and Last Names

Relationship

Cell Phone

Email

Home Phone

MEDICAL INFORMATION

Allergies or Medical Condition(s):

Doctor’s Name *

First

Last

Insurance Carrier

Doctor’s Phone Number

Policy Number

REQUIRED CONSENT

PERMISSION TO TREAT A MINOR: I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the managers, coaches, or parents of team members acting in the capacity of activity supervisors or vehicle drivers, as my Agents, to consent to medical, surgical, or dental examination and/or treatment in the event of any injury caused by a direct or an indirect result of the participant’s participation in Baseball Heritage Museum/BHM Buckeyes Baseball Club activities.

INFORMED CONSENT: I, the parent or legal guardian of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. In consideration for accepting the registration of the above named individual and permitting voluntary participation of said individual in its programs, I hereby release, discharge, and hold harmless Baseball Heritage Museum, its volunteers and other representative from any claims arising out of or relating to any physical injury that may result to said individual while participating in Baseball Heritage Museum/BHM Buckeyes Baseball Club sponsored events, including any physical injury caused by the negligence of any official, manager or coach while performing his/her duties during any practices or games.

PHOTO RELEASE: I hereby give permission and authorize Baseball Heritage Museum/BHM Buckeyes Baseball Club, its agents, coaches, and parents to photograph or electronically or digitally record my image (and/or that of my minor child) for publication in printed or electronic form, and for my image (or that of my minor child) to be seen and disseminated to the general public in any media form, including, but not limited to advertising, posters, video or website. I specifically waive any rights and claims that I may have or claim for privacy, invasion of privacy, libel, payment or royalties for use of the above described photograph.

BHM WAIVER: (For parents/guardians of minority age-Under 18 at time of registration) This is to certify that I am a parent/guardian with legal responsibility for this participant, that I do consent and agree to his/her release as provided above all the Releases, and that, for myself, the minor child, and all heirs, executors, administrators, successors, assigns, personal representatives and next of kin, I release and agree to identify and hold harmless the Releases from any and all liabilities incident to the minor child’s involvement or participation in any activities authorized or supervised by Baseball Heritage Museum/BHM Buckeyes Baseball Club as provided above, EVEN IF ARISING FROM THE NEGLIENCE OF THE RELEASEES, to the fullest extent permitted by law. I acknowledge full responsibility for the supervision of the minor child, I recognize that participation may involve activity that involves a risk of harm, and I fully assume those risks on behalf of the minor child.

Today's Date *

Parent/Guardian Signature *

Clear Signature

PLAYER INFORMATION

EMERGENCY CONTACT INFORMATION

MEDICAL INFORMATION

REQUIRED CONSENT

Museum Hours

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