Does your child require special care or any disabilities?
2011 NJTL Medical Information & Waiver Form
If yes, please specify:
If yes, please specify:
If yes, please specify:
If yes, please specify:
Is your child currently taking any prescribed medication?
Does your child have an existing or previous illness?
Has your child been hospitalized in the past 12 months?
Does your child have any known allergies to foods, insect stings or medications?
In consideration of myself or my child, being allowed to participate in the National Junior Tennis League (N.J.T.L.), sponsored by CTTA and the City of Austin Parks and Recreation Department, I, the undersigned parent, binding heirs, executors, administrators, estate and assigns, do hereby release and agree not to hold liable the CTTA and/or the City of Austin Parks and Recreation Department, its officers, agents and employees; from any and all actions causes of action, claims, demands, costs or damages as a result of property damages or personal injuries or death sustained by me or my said child or his/her or my property, arising from or resulting from an act or omission, negligent or otherwise, of CTTA, the City of Austin, the N.J.T.L. program, its officers, agents and employees or any other person or at any participant in the program while participating in the said activity or while traveling to or from the place at which such activity will be conducted.
-- Consent is hereby given for the applicant to participant in the N.J.T.L. program and permission is given for any emergency medical treatment, operation, or anesthesia, which might become necessary. I agree to be responsible for the expense of medical treatment of service.
Child's Name:
Physician Name:
Physician's Telephone:
-- I do not give consent for any emergency medical treatment, operation, or anesthesia, which might be deemed necessary. I agree to be responsible for all outcomes due to my decision. (Applicant may still participate in the N.J.T.L. program.)
Additional Information or Phone:
CTTA and Park and Rec. are non-profit 501c3 organizations
