All Star Tennis Acceptance | Mississippi Coaches Association: Online Forms

PLAYER AGREEMENT

Name (as you would like it to appear in the Program Book)*

First Last

High School*

Agreement*

I accept the invitation to play in the 2022 All-Star Tennis Tournament directed by the Mississippi Association of Coaches, and agree to:
Follow all the rules and regulations of the host college and the Mississippi Association of Coaches;

Notify the Association immediately if circumstances change affecting my decision or ability to play, so that an alternate can have the chance to play and receive full benefits and honors;

By accepting this invitation I pledge my full support to my team and coaches and agree to accept all the responsibilities which go along with the honor. These responsibilities include meeting all deadlines, supplying requested information and reporting on time.
I will not be able to participate in the 2022 All-Star Tennis Tournament
(If you will not be able to participate, please notify the MAC office as soon as possibly by phone 601-924-3020; Fax: 601-924-3050; E-mail: sangelo@mscoaches.com )

T-Shirt Size:*

Small
Medium
Large
Xtra-Large

CONSENT TO MEDICAL TREATMENT

Player Name*

First Last

Date of Birth*

Age*

Phone*

Parent/Guardian #1*

First Last

Parent #1 Email*

Parent/Guardian #2

First Last

Parent #2 Email

Mailing Address*

Street Address City State ZIP Code

Family Physician*

First Last

Physician Office Phone*

I/We am/are the athlete's*

Parent(s)
Guardian
Conservator

Part I*

I/We am/are the parent(s) of the athlete listed above and state that he/she has no guardian or conservator appointed by law.

Part I*

I/We am/are the guardian/conservator of the athlete listed above as appointed by law.

Part II*

I/We in the same capacity as indicated in Part I authorize the Mississippi Association of Coaches to take whatever medical steps are deemed necessary in case of injury and/or illness (including giving authorization to duly qualified medical personnel to administer such medical or surgical treatment to include anesthetics and/or drugs as the duly qualified medical personnel deem necessary in the diagnosis and treatment) of the athlete list above during his/her participation in the 2022 All-Star Tennis Tournament June 9, 2022. Treatment of any such injury and/or illness shall begin immediately upon its discovery.

Part III

Insurance Coverage*

The Above named participant is covered by hospitalization insurance.
The Above named participant is not covered by hospitalization insurance.

Policy #:*

Name of Insurance Company*

Address of Insurance Company*

Street Address City State ZIP Code

If Group Policy, give Employer

Group #

STATEMENT OF UNDERSTANDING & NOTICE OF INSURANCE COVERAGE

I, the undersigned parent(s) and/or guardian(s) of the participant named above, a participant in the 2022 All-Star Tennis Tournament, do understand that the insurance coverage provided for all the participants in this tournament is known as secondary coverage. This specifically means that my personal insurance company’s policy is the primary coverage for my son/daughter and will be considered primary in the event my son/daughter suffers an accidental injury requiring medical attention, evaluation and/or treatment during any All-Star Activities June 9, 2022.

I further understand that the Mississippi Association of Coaches does provide insurance coverage to my son/daughter, but such coverage is secondary, specifically meaning that such coverage only becomes applicable after my coverage, if any, has first been utilized to cover the expenses and fees for such medical treatment. Moreover, I have been informed that the coverage provided by the Mississippi Association of Coaches may have certain deductions, exclusions and upper limits so as not to provide full coverage to my son/daughter even if the insurance is utilized after exhausting my personal coverage, if any.

I further understand that the Mississippi Association of Coaches provides such coverage for the benefit of the participants in the 2022 All-Star Tennis Tournament and their parents, and such insurance coverage possibly may not cover all bills, expenses and other costs incurred by the participants while participating in the 2022 All-Star Tennis Tournament at the Parham Bridges Tennis Center, Jackson, MS. Toward that end, I have been placed on notice by the Mississippi Association of Coaches and its representatives that if additional insurance coverage is needed for my son/daughter, I should provide such insurance at my own expense.

Attestation*

I hereby state that the information provided on the Medical Consent form is the correct name, address and policy number of the present health, accident and hospitalization insurance providing coverage for my son/daughter. If such coverage is changed, lapses or terminates for any reason, I hereby agree to update and supplement the information provided and to ensure that the Mississippi Association of Coaches and its representatives are provided with current information relating to insurance up and through the date of the Tournament.

SIGNATURES

Date

Player Signature*

Parent #1 Signature*

Parent #2 Signature

Guardian Signature*

2022 All-Star Tennis Acceptance

PLAYER AGREEMENT

CONSENT TO MEDICAL TREATMENT

Part III

STATEMENT OF UNDERSTANDING & NOTICE OF INSURANCE COVERAGE

SIGNATURES