Usav Youth & Junior Volleyball Player Medical Release Form
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1THIS FORM IS TO BE CARRIED TO ALL SANCTIONED COMPETITIONS & PRACTICES.
2014-2015 USAV YOUTH & JUNIOR 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. I understand and agree that this
document will be kept in the possession of authorized adult team personnel and that reasonable care will be used to keep this information
confidential. By signing this form the participant affirms having read and agreed to the terms and conditions listed below.
Club:
Team Name:
Southwest Sunset Volleyball Club
Male
Female
First Name
Last Name
Birth Date
Age
Primary Contact: Parent or Guardian
Name:
Address:
City, State & Zip
Primary Phone:
Alternate Phone:
Secondary Contact:
Parent/Guardian
Other
Name:
Primary 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:
Please list any medications currently being taken:
In the past 24 month, have you been tested, diagnosed and/or treated for a concussion:
Yes
No
If yes, provide the date (month and year), who performed the testing/diagnosing/treatment and what was the outcome:
Please list any allergies:
If None, please write None.
Participant Signature
Date:
(regardless 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 understand and agree that this document will be kept in the
possession of authorized team/RVA personnel and that reasonable care will be used to keep this information confidential. I agree to
allow the authorized adult team personnel to release this information in the event of a medical emergency to a third party medical
provider. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities
described above.
X
Parent/Guardian Signature:
Date:
Relationship to Participant:
If, during the course of my daughter's/son's activities in volleyball, should she/he become ill or sustain an injury, I hereby
____ AUTHORIZE
or
____ DO NOT AUTHORIZE (Select only one option to ensure validity of this document!)
you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.
Parent/Guardian Signature:
X
Date:
STATE OF
) COUNTY OF
)
SWORN TO BEFORE ME, a Notary Public, by said
personally known
to me this
day of
,20
My Commission Expires
Notary Public
Revised 09/1/2012 SB
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