The Old South Tournament-Registration Consent and Release Form
OST 10TH LOGO

OLD SOUTH TOURNAMENT - RELEASE AND
CONSENT FORM

Registrant's Name:   Age: 
Address:  City:  State:   Zip Code: 
Chapter Name:  Location: 
  1. I, the undersigned Parent/Legal Guardian of  do hereby give my consent and permission for him/her to participate in The Order of DeMolay Old South Tournament held in New Orleans, Louisiana.
  2. In the event of injury of illness to the above named minor, I, the undersigned Parent/Legal Guardian hereby authorize any adult DeMolay Advisor or Old South Tournament staff member in attendance to secure and any physician in attendance to provide such emergency medical treatment as shall be deemed necessary by those present, including, but not limited to hospitalization, injections, anesthesia, surgery, x-ray, blood and medication. I understand that every reasonable effort will be made to contact me prior to medical treatment.
  3. The above named minor is subject to the following medical problems and/or is receiving treatment under the supervision of proper medical authorities as follows: (Write on the line below or write NONE)
  4. Neither DeMolay International, any DeMolay jurisdiction or The Old South Tournament maintains any medical insurance for its members. I understand that I will be responsible for any and all costs of medical treatment incurred by or on behalf of:

    My family health insurance carrier and policy numbers are as follows:

    Name of Insurance Co.   Policy Number     Name of Policy Holder
  5. I, the undersigned Parent/Legal Guardian, AND the undersigned YOUTH(legal minor), do hereby agree that we will abide by the Statutes, Rules, Regulations and Edicts of DeMolay International, and its duly authorized representative(s). We agree that, if in the opinion of any DeMolay Advisor or Old South Tournament staff member, either of us should be removed or asked to leave any DeMolay activity for violation of the same, that the undersigned Parent/Legal Guardian will immediately take the necessary action to cause the transportation of the violator from the activity site at the expense of the Parent/Legal Guardian.
  6. We hereby agree to release and hold harmless DeMolay International, the Grand Master of DeMolay International and its members, together with the Executive Officer, staff members and Old South Tournament Director and its Executive Board members and staff, Order of DeMolay from any and all claims or cause of action which the undersigned has or may have. This specifically includes any and all claims which arise out of attendance at The Order of DeMolay Old South Tournament, including transportation to and from said event.
  7. IN THE EVENT OF AN EMERGENCY AND THE UNDERSIGNED PARENT/LEGAL GUARDIAN CANNOT BE REACHED, THE UNDERSIGNED PARENT/LEGAL GUARDIAN HEREBY AUTHORIZES THE FOLLOWING PERSON TO ACT ON THEIR BEHALF:
    Name:  Telephone #:
    Address:   Relationship:
  8. Parent/Legal Guardian, please provide the following information about yourself:
    Full name: 
    Address: 
    City:   State:   Zip: 
    Home Phone #:   Work Phone #: 
    Relationship to YOUTH: 
  9. If YOUTH's address is different than Parent/Legal Guardian, state on line below. If same, write SAME.
Signature of Parent/Legal Guardian
Signature of YOUTH (legal minor)