Registration/medical Release Form printable pdf download

MICHIGAN ELITE VOLLEYBALL ACADEMY

Registration/Medical Release

(one form per athlete please)

Player Name:_______________________________Graduation Year:_______ DOB__________

Mothers Name:______________________________ Phone:____________________________

Address:______________________________________________________________________

# and street

city

state

zip

Mother’s email:_________________________________________________________________

Father’s Name:_______________________________phone:___________________________

Address:______________________________________________________________________

# and street

city

state

zip

Father’s

Email:________________________________________________________________________

Emergency Contact (if no parent can be reached):___________________________________

Phone:__________________________Relationship to child:_____________________________

Permission to Treat

As custodial parent or court-appointed guardian of the above mentioned child, I do for both of child’s parents, for

child’s heirs and successors, release Michigan Elite Volleyball and any of its agents, employees, representatives, and

the Elite Sport Centers, from all claims rising out of or connected with child’s in any Michigan Elite Volleyball event,

camp or practice. I provide this release because I am mindful that athletics, physical training and competition can be a

dangerous undertaking regardless of how careful or prudent any person, firm or facility might be. Further, I give

permission to Michigan Elite Volleyball to treat Child or arrange for medical care or treatment for Child in any

situation deemed reasonably necessary by Michigan Elite Volleyball.

In the event neither emergency contact can be reached or is the urgency of the situation requires immediate attention

without prior telephone contact, Michigan Elite Volleyball, may arrange for medical treatment for the Child at the

expense of the parent or guardian signing this form. Health Insurance information for child is as follows:

Insurance Co.___________________________________policy number______________________________________

Address:____________________________city______________________state__________zip___________________

Telephone:_______________________________________________________________________________________

In order to seek appropriate medical attention and treatment of Child, please disclose the following:

Allergies:________________________________________________________________________________________

Heart Disease, Asthma, seizures, diabetes or other:_______________________________________________________

Any conditions either physical or mental that would or might affect the child’s participation in Michigan Elite

Volleyball Club activities:__________________________________________________________________________

Medications:_____________________________________________________________________________________

I have read the above and answered all questions to the best of my knowledge, thereby releasing Michigan

Elite Volleyball Academy from any liability.

Signed:_____________________________________________________________date:______________

If athlete is over 18, Sign:_______________________________________________date:______________

Camp/Session Code

East or West (indicate)

Total:______________

Credit Card online

Check#_____________

Cash:_____________

Registration/medical Release Form

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