Weva Hp Medical Release Form - Western Empire Volleyball

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Western Empire Volleyball Association High Performance Program
Tryouts, Camps and Teams
Player Medical History and Release Form
58 Meadowlark Drive
Penfield, NY 14526
585-259-6557
This form must be completed - legibly - and signed in all indicated areas by the participant and parent or
guardian of the participant.
By signing this form the participant’s parents or guardians affirm having read it.
Athlete:
Last Name ____________________________________________ First Name ________________________________________
Birth date _________________________________ Current age _________________________ Gender__________________
Parent or Guardian:
Medical Information:
Name ____________________________________________
Family Physician:________________________________
Address _________________________________________
_________________________________________________
City _____________________ St. _______ Zip__________
Physician Phone:_________________________________
Home Phone _____________________________________
Primary Insurance Co: ___________________________
Work Phone ______________________________________
_________________________________________________
Cell Phone _______________________________________
Primary Group Policy #: __________________________
_________________________________________________
Emergency Contact:
Name ____________________________________________
Relationship to athlete ___________________________
Home phone _____________________________________
Work phone ______________________________________
Cell phone _______________________________________
Participant, _____________________________________________, has my permission to participate in training,
competition, events, activities and travel sponsored by USA Volleyball or any of its Regional Volleyball Associations (RVAs). I
approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I
certify that the participant has full medical insurance with the company listed above. I also certify to the best of my knowledge that
the participant named hereon is physically fit to engage in the activities described above.
Participant Signature ___________________________________________ Date _____________________________________
Parent / Guardian Signature ______________________________________________ Date ____________________________
Relationship to athlete ___________________________________________________
To the staff:
If, during the course of my son / daughter’s activities related to WEVA High Performance volleyball, he/she should become ill or
sustain an injury, I hereby authorize you to obtain emergency medical / dental care.
I will assume financial responsibility for bills and costs incurred through my insurance company.
Parent / Guardian Signature ______________________________________________ Date ____________________________
I do NOT authorize emergency medical /dental care for my son / daughter.
Parent / Guardian Signature ______________________________________________ Date ____________________________

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