Medical Release Form

THIS FORM IS TO BE CARRIED TO ALL SANCTIONED  COMPETITIONS & PRACTICES.

   Revised 08/01/2013

 

2017-2018 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. 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 confidentail.  By signing this form the participant affirms having read and agreed to the terms and conditions listed below.

 

Club:  _____________________________                                 Team Name:  _____________________________________             

Name (Last) ____________________________  (First) ______________________________ Birth Date  ____/____/____  

Age  ______  Gender  ________

Primary Contact: Parent or Guardian

Name ____________________________ Address   ____________________________
City:   ____________________    St. _________    Zip: ___________                                                                                                    

Primary 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:

 
In the past 24 months, 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: ____________________________

 

Any allergies - If None, please write None:

 

Participant

Signed ____________________________________                        Date:   _______________

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 adult team 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. 

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

 

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