Special Needs Medical Release And Uniform Order Form printable pdf download

PARTICIPANT’S NAME:_____________________________________ Date of Birth_______________

HOME ADDRESS: _________________________________CITY/ST/ZIP_________________________

I, the undersigned parent and/or legal guardian of the child/ward named below, hereby give

permission for my child/ward to participate in the Special Needs Soccer Association, SPENSA, program

and related activities. I understand that soccer is a contact sport involving strenuous physical activity and

acknowledge the possible risk of harm to my child/ward from participating in soccer, including, but not

limited to, serious physical injury. I further acknowledge that the risk of possible physical harm to my

child/ward may by increased as a result of the following pre-existing conditions:

____________________________________________________________________________

(Please list the name of disability)

I understand I am solely responsible for any medical expenses that may occur as a result of my

child’s/ward’s participation in this program. Additionally, I hereby authorize SPENSA and its directors,

officers, volunteers, and agents to take all steps deemed reasonably necessary to obtain emergency

medical care for my child/ward in the event that I am not present on the premises at the time of any

medical emergency.

Notwithstanding that my child’s/ward’s participation in youth soccer constitutes a greater risk to my

child/ward than to other athletes, I nevertheless hereby consent to my child’s/ward’s participation in order

to take advantage of the benefits associated with youth sports programs. In consideration of SPENSA

allowing my child/ward to participate in the SPENSA program and related activities, I agree on behalf of

myself, my family, my child/ward, and our legal representatives, heirs and assigns to waive, release and

hold SPENSA, Saint Louis University, Kolping Soccer Club, the Missouri Youth Soccer Association,

Anheuser Busch, the Anheuser Busch Centre and their respective directors, officers, employees,

volunteers, agents and affiliated or participating referees, youth players, soccer clubs, organizations or

associations (the Releasees) harmless from any liability, claims, actions, damages, suits, expenses, costs

and fees), relating to my child’s/ward’s participation in the program and activities, notwithstanding any

potential negligence on the part of the Releasees. Nothing contained herein shall be construed as an

assumption of risk, waiver, or release of any claims relating to the intentional and willful acts of any

Releasees. I further agree to grant SPENSA the irrevocable right to use my child’s/ward’s name, picture

and/or likeness in any printed materials, broadcast and other media, for the purpose of publicizing or

marketing SPENSA and its programs and activities.

In my opinion, there is no reason why the above-named individual should not participate in the Special

Needs Soccer Association (SPENSA).

_______________________________________________

__________________________________

Print Physician’s Name

Physician’s Signature

Date

Physician’s Telephone Number_______________________ Exchange Number ____________________

Therefore, I grant ________________________and/or_______________________ permission to

act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or

dentistry. I also assume the financial responsibility for any medical treatment for my child.

Signature of Parent/Guardian__________________________________ Date______________________

Special Needs Medical Release And Uniform Order Form