Usa Youth & Junior Olympic Volleyball Player Medical Release Form
ADVERTISEMENT
1THIS FORM IS TO BE CARRIED TO ALL SANCTIONED COMPETITIONS & PRACTICES.
2009 USA YOUTH & JUNIOR OLYMPIC VOLLEYBALL
PLAYER MEDICAL RELEASE FORM
This must be completed - legibly - and signed in all areas by both the player and his/her parent or
guardian. By signing this form the participant affirms having read it.
Name
Last
First
Birth Date
Age
Gender
Primary Contact: Parent or Guardian
Name
Address
Zip
Phone
Alternate Phone
Secondary Contact: ___ Parent/Guardian ___ Other
Name
Phone
Alternate Phone
Primary Insurance Co.
Primary Group/Policy #
Family Physician Name
Physician Phone
Please elaborate on any medical conditions of which we should be aware:
Any medications currently being taken:
Any allergies:
If None, please write None.
Signed
Date:
Participant
Parent or Guardian of Athletes under 18 years of age.
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.
Signed
Relationship:
Date:
If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain an injury, I hereby
authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through
my insurance company.
Signed:
Date:
Parent or Guardian
or
I do not authorize emergency medical/dental care for my daughter/son.
Signed:
Date:
Parent or Guardian
.
Revised 08/06/2008
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal