USMC Mud Run 2011 JROTC/Child Volunteer (under 18)Consent Form

Name______________________________________________Date of Birth__________ School/Organization_______________________________________________________ Allergies________________________________________________________________ Emergency Contact Information Name_____________________________________Phone #_______________________ Name_____________________________________Phone #_______________________ Name_____________________________________Phone #_______________________ Day of Cell Phone Number contact (this person must be present day of and reachable by medical staff) Detachment Commander and/or person present day of: Name_____________________________________Cell Phone #___________________ Name_____________________________________Cell Phone #___________________ As the parent/legal guardian, I __________________________________ give my permission for _________________________________ to participate in the April 16, 2011 USMC Mud Run. I also grant permission for the treatment deemed necessary for any condition arising during the participation in this event, including medical or surgical treatment that is recommended by a medical doctor. I grant permission for athletic trainers, nurses, paramedics, as well as physicians or those under their direction who are a part of the Mud Run injury prevention and treatment team to have access to necessary medical information. I know and understand the risk of injury to my child/ward comes with participation in this event. I have had the opportunity to understand the risk of injury during the participation of the Mud Run through meetings, written information, or by some other means. My signature indicates that to the best of my knowledge, my answers to the above information are complete and correct. I understand that the data acquired during these evaluations and treatments may be used for research purposes. Signature of Participant______________________________________Date___________ Signature of Parent/Legal Guardian____________________________Date_____________