Player Medical Informational Release And Waiver - Kc Select printable pdf download

Player Medical Informational Release And Waiver - Kc Select

Player Medical Informational Release and Waiver

Player Name: __________________________________ Date of Birth: _______________

Parents Names: ________________________

_________________________________

Address: _____________________________City: _____________ State: ___ Zip: _____

Contact Number 1 (___) ________________

Contact Number 2 (___) ____________

Emergency Contact

Name: _______________________________

Contact Number (___) ______________

Medical Conditions or allergies: _______________________________________________

Primary Medical Insurance Company : ________________________________________

Policy Holder : _________________________

Policy Number: ___________________

Contact Telephone Number: (____) _________________________

Parent/Guardian Release

I hereby release, discharge and indemnify USSSA/USSF all owners and operators of facilities used for

events, and all directors, officers, employees, agents and representatives from all claims, liabilities,

damages or causes of actions arising from any connection with my child's participation in all programs.

My child has received a physical examination by a physician and has been passed healthy and capable

of participating in all programs. I recognize the possibility of physical injury associated with soccer and

I hereby give my consent to medical treatment by an athletic trainer and/or doctor of medicine and/or

dentistry.

I have read the above and understand that I/we have given up substantial rights by signing this release

at our own freewill.

Parent Signature: _______________________

Date: _____________________

Player Medical Informational Release And Waiver - Kc Select