Department of Health, Physical Education and Athletics


Dec 2, 2015 - 900 Wood Rd., PO Box 2000. Kenosha, WI. 53141. Office: 262-595-2164. Fax: 262-595-2225. TRYOUT CONSENT AND EMERGENCY FORM.

Director of Sports Medicine 900 Wood Rd., PO Box 2000 Kenosha, WI. 53141 Office: 262-595-2164 Fax: 262-595-2225

TRYOUT CONSENT AND EMERGENCY FORM PROSPECTIVE STUDENT-ATHLETE CONTACT INFORMATION Prospect Name: _______________________________________ Sport: _________________ Address: ____________________________ City/State: __________________ Zip: ________ Cell Phone: ___________________ Home Phone: _________________ Birthdate: __________ Tryout Date: __________________ Known Allergies and or Medical Alerts: ____________________________________________

__________________________________________________________________

EMERGENCY CONTACT INFORMATION Names: ____________________________________ Relation to Athlete: ________________ Address: ________________________________ City/State: _______________ Zip: _______ Cell Phone: ______________ Home Phone: ______________ Work Phone: ________________

CONSENT TO TREAT

I give authorization to the UW-Parkside Sports Medicine Staff to evaluate and treat injuries that occur during my tryout participation at the University of Wisconsin – Parkside. This consent includes, but is not limited to administration of immediate first aid and treatment, x-rays, physical exam, follow-up and rehabilitation on the day of the tryout in the athletic training facility. I give authorization for my medical record to be released from the UW-Parkside Sports Medicine Staff to my medical care providers and from my medical care providers to the UW-Parkside Sports Medicine Staff. I understand that the UW-Parkside Sports Medicine Staff has the authority to prohibit me from further participation because of injury, disqualifying medical condition, and/or because of an undue risk to the University of Wisconsin – Parkside. (Initial Here to Indicate Authorization: ________)

ASSUMPTION OF RISK I hereby acknowledge that I understand that many of the activities performed as a part of participation in an athletic tryout involve substantial risk of injury. I further agree that I understand that all participation in intercollegiate athletics at the University of Wisconsin – Parkside is voluntary. In consideration of the University making any equipment and/or facilities available to the intercollegiate programs and/or participants in such activities, I hereby release the University of Wisconsin – Parkside, its successors, assigns, officers, agents, and all employees from any claims, demands and cause of action whatsoever in any way growing out of or resulting from participation in the activities of any intercollegiate sport. (Initial Here to Indicate Acknowledgement: ________) I additionally understand that the University of Wisconsin – Parkside does not provide medical insurance for participation in tryouts and that I am solely responsible for any and all medical expenses that are incurred as a result of my participation. __________________________________________________ Prospective Student-Athlete Signature

________________ Date

__________________________________________________ ________________ Parent or Legal Guardian Signature (if prospective student is a minor) Date

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