Olympic Development Program Player Medical Release Form printable pdf download

OLYMPIC DEVELOPMENT PROGRAM

PLAYER MEDICAL RELEASE FORM

PLAYER’S NAME___________________________________________________DATE OF BIRTH________________

ADDRESS__________________________________________CITY________________STATE_____ZIP__________

SOCIAL SECURITY NUMBER _______-_______-_______

EMAIL ADDRESS __________________________

EMERGENCY INFORMATION

MOTHER’S NAME__________________________________HM PH (_____)__________WK PH (_____)__________

FATHER’S NAME___________________________________HM PH (_____)__________WK PH (_____)__________

IN AN EMERGENCY WHEN PARENTS CANNOT BE REACHED, PLEASE CONTACT:

NAME___________________________________________HM PH (_____)__________WK PH (_____)__________

ALLERGIES____________________________________________________________________________________

OTHER MEDICAL CONDITIONS____________________________________________________________________

PLAYERS PHYSICIAN_______________________________HM PH (_____)__________WK PH (_____)__________

MEDICAL AND/OR HOSPITAL INS. CO.___________________________________________PH (_____)__________

(PLEASE COPY BOTH SIDES OF YOUR MEDICAL INSURANCE CARD AND ATTACH TO THIS FORM)

POLICY HOLDER ____________________________________POLICY #__________________GROUP #_________

PARENTS APPROVAL AND MEDICAL RELEASE

RECOGNIZING THE POSSIBILITY OF PHYSICAL INJURY ASSOCIATED WITH SOCCER AND IN CONSIDERATION FOR THE USSF/USYSA AND ITS

AFFILIATES ACCEPTING THE REGISTRANT FOR ITS SOCCER PROGRAMS AND ACTIVITIES (THE “PROGRAMS”), I HEREBY RELEASE,

DISCHARGE, AND/OR OTHERWISE INDEMNIFY THE USSF/USYSA, IT’S AFFILIATED ORGANIZATIONS AND SPONSORS, THEIR EMPLOYEES AND

ASSOCIATED PERSONNEL, INCLUDING THE OWNERS OF FIELDS AND FACILITIES UTILIZED FOR THE “PROGRAMS” AGAINST ANY CLAIM BY

OR ON BEHALF OF THE REGISTRANT AS A RESULT OF THE REGISTRANT’S PARTICIPATION IN THE “PROGAMS” AND/OR BEING

TRANSPORTED TO OR FROM THE SAME, WHICH TRANSPORTATION I HEREBY AUTHORIZE.

MY SON/DAUGHTER HAS RECEIVED A PHYSICAL EXAMINATION BY A PHYSICIAN AND HAS BEEN FOUND PHYSICALLY CAPABLE OF

PARTICIPATING IN THE “PROGRAMS”. I HEREBY GIVE CONSENT TO HAVE AN ATHLETIC TRAINER AND /OR DOCTOR OF MEDICINE OR

DENTISTRY PROVIDE MY SON/DAUGHTER WITH MEDICAL ASSISTANCE AND/OR TREATMENT AND AGREE TO BE RESPONSIBLE FINANCIALLY

FOR THE REASONABLE COST OF SUCH ASSISTANCE AND/OR TREATMENT.

SIGNATURE OF PARENT/GUARDIAN_____________________________________DATE__________

SUBSCRIBED AND SWORN TO BEFORE ME THIS __________ DAY OF_________________, 20_____

NOTARY PUBLIC___________________________________MY COMMISSION EXPIRES__________

(

RAISED SEAL OR ORIGINAL STAMP - NOTARY SEAL IS MANDATORY)

Olympic Development Program Player Medical Release Form