Lone Star Transplant Games WAIVERS These forms must be completed by each competitor (and recipient's physician), and received prior to the event, in order for the competitor to be eligible to compete. Please print clearly in blue or black ink. Recipients must have a functioning transplant for at least six (6) months to be eligible for competition, unless authorized by a physician in writing.

Liability Waiver     (Required for all participants)           Home Page  ·   Back

I intend to participate in the Lone Star Transplant Games.
I hereby agree to hold harmless and disclaim any liability against Lions Clubs International, participating local Lions Clubs, their teams, committees and members, the owners and operators of Game locations and all other sponsors of the Games.
As an athlete, I attest that I have been training for these Games and that I am medically fit.

Name of Registrant (printed): ______________________________________________

Signature of Registrant: _________________________________   Date: ____________

______________________________________________
      Signature of Parent or Guardian (if participant is a minor)

I hereby consent that the photographs/videos in which I appear may be used by the Lions Clubs and their assignees or succesors, for the sole purpose of education or publicity. This consent is expressly intended to release from liability all personnel of the participating Lions Clubs, Lions Club International, Lions Eye Bank of Central Texas, as well as their organizations.

Name: ______________________________________________________________

Signature: ____________________________________________________________

Address: _____________________________________________________________

City:_______________________________   State: ____________   Zip: __________

Phone: ______________________________________   Today's Date: ___/___/____

_________________________________________________
      Signature of Parent or Guardian (if participant is a minor)

Lone Star Transplant Games Medical Information (Required for Transplant Recipients)

Last Name: ____________________________   First Name: ______________________

Address: _______________________________________________________________

City:________________________________   State: ______________   Zip: __________

Day Phone: _______________   Evening: ______________   Date of Birth:__________

Fax Number: ___________________   E-mail: _________________________________

Date of (Last) Tansplant: ______________   Hospital: ____________________________

Transplant Surgeon/Physician: _________________________   Phone: ______________

Type of Transplant: ______________   Allergies: _______________________________

______________________________________________________________________

In case of emergency during the games, please contact:

Name: _______________________________   Relationship: ______________________

Day Phone: ____________________   Evening Phone: ____________________

Please list prescription and non-prescription medications and dosages: ________________

________________________________________________________________________

________________________________________________________________________

I am competing in the following events (list specific events): _____________________

________________________________________________________________________

Total number of events: ___________________

Lone Star Transplant Games Physician Release (Required for Transplant Recipients)

This form must be completed by each competitor's physician in its entirety prior to the event in order for the competitor to be eligible to compete. Please print in blue or black ink.
Recipients must have a functioning transplant for at least six (6) months in order to be eligible for competition, unless authorized by a physician in writing.

Athlete's Last Name: __________________________   First Name: _________________________

The athlete named above has indicated the event(s) in which he or she wishes to compete in the
Lone Star Transplant Games. Please review and check one of the following:

I have reviewed the proposed event(s) for this athlete as listed and approve
        his/her participation in all of the events listed (number of events listed: _______ ).
I have reviewed the proposed events for this athlete as listed and do not approve
        his/her participation in any of the events listed.
I have reviewed the proposed events for this athlete as listed and do not approve
        his/her participation in the followng events listed:

______________________________________________________________________________

Date of Birth:_____/_____/______       Blood Pressure: ___________ / ___________
Diabetic: Yes   No          Is this individual in good general health? Yes   No

Other health issues, special needs, comments: ________________________________________

______________________________________________________________________________

I certify that I have reviewed the above information, examined the above-named competitor and
have concluded that he/she is fit to compete as indicated above in the Lone Star Transplant Games.

______________________________________________________________________________
          Signature of Physician                                                                                        Date

______________________________________________________________________________
          Name of Physician (Please Print)                                        Phone                      Fax

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          Address                                                            City                          State          Zip