Medical Release Form, General Release printable pdf download

Wellesley United Soccer Club

Memorial Day Tournament

MEDICAL RELEASE FORM

As the parent/legal guardian of ___________________________, I request that in my absence the above-named

player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians,

dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians

or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment. I

authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of Player’s Birth ____/____/____

Date of last Tetanus Booster _____/_____/_____

Month Day Year

Known allergies of this player, including any allergies to medicine _________________________________

Any other medical problems which should be noted _____________________________________________

Family Physician _____________________________________

Phone ____________________________

Name of Parent/Guardian

___________________________________________________________

Address__________________________________________________________________________

City/State/Zip _____________________________________________________________________

Phone (H) ______________ (W) ________________ (Email) _____________________________

Person responsible for charges (if different from above) _____________________________________

Address____________________________________________________________________________

City/State/Zip_______________________________________________________________________

Phone (H) __________________ (W) ________________ (Email) ____________________________

Person to notify if parent/guardian is unavailable ___________________________________________

Phone (H) _______________ (W) _______________ (Email)_________________________________

Insurance Carrier ___________________________________ Policy Number ____________________

Signature of Parent/Guardian

_______________________________________________________

GENERAL RELEASE

This form must be read and signed before the participant takes part in the WUSC Invitational Tournament (the

Tournament). By signing this form, the participant’s Parent/Guardian represents and affirms: that s/he has the power and

authority to execute this Medical Release and General Release (the “Release”) on behalf of the participant; that s/he has

read the Release; and acknowledges having had sufficient opportunity to have the Release reviewed by participant’s

counsel.

On the behalf of the participant’s family, parents, guardians, heirs, successors and assigns, I herby forever release,

discharge, agree to hold harmless, and covenant not to sue Wellesley United Soccer Club, Inc. (“WUSC”), each of its

officers, directors, employees, agents, shareholders, members, partners, representatives, and all owners and operators of all

sites at which WUSC conducts the Tournament and their respective affiliates, and all the representatives (collectively the

“released parties”) from any and all liabilities, harm, claims, costs, demands or causes of action, whether known or

unknown (“claims” ) that I may now have or hereafter have for injuries or damages arising out of my participation in the

Tournament.

I understand and acknowledge that dangers of personal injury are inherent in participating in soccer games and related

activities and I expressly and voluntarily assume all risk of death, harm and/or personal injury sustained in the games and

related activities, including but not limited to the risks incurred in all these activities and those arising from hidden, latent

or obvious defects in any facilities or equipment used. I acknowledge the possibility that neither I, nor my successors may

fully know the number or magnitude of all claims, and agree that this release is a full and final release of all claims. This

release is intended to be binding on the participant’s family, parents, guardians, heirs and assigns. This release is being

signed in consideration of the opportunity to play in the Tournament. It is an agreement made under seal and is governed

by Massachusetts law.

Name of Participant_______________________________________________________

Parent/ Guardians signature_________________________________________________ Date ____/____/____

Medical Release Form, General Release

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