Fillable Printable Medical Waiver Form - Illinois

Medical Waiver Form - Illinois

Emergency Medical Release & Liability Waiver

Participant’s Name____________________________________________________ Birthdate________________________

Street Address ____________________________________City _________________________________ Zip___________

EMERGENCY INFORMATION

Father's Name______________________________

Home Phone (_____)____________ Cell/Bus Phone (_____)____________

Mother's Name _____________________________

Home Phone (_____)____________ Cell/Bus Phone (_____)____________

In an emergency when parent/guardian cannot be reached or is not applicable, please contact the following:

Name_____________________________________

Home Phone (_____)____________ Cell/Bus Phone (_____)____________

Name________________________________ Home Phone (_____)____________ Cell/Bus Phone (_____)____________

Allergies____________________________________________________________________________________________

Other Medical Conditions_______________________________________________________________________________

Physician___________________________________ Cell Phone (_____)____________ Bus Phone (_____)____________

Medical/Hospital Insurance Company_________________________________________ Phone (_____)________________

Policy Holder's Name_______________________________________ Policy Number_______________________________

THIS AUTHORIZATION FOR EMERGENCY MEDICALTREATMENT MUST BE COMPLETED BEFORE PARTICIPANT

(PLAYER/COACH/REFEREE) CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON

INFORMATION PROVIDED HEREIN.

I the undersigned participant and parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand

that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and

economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of

play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at

this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death,

hereby release, discharge, covenants to indemnify and not to sue Illinois Youth Soccer Association, its directors, officers, employees, coaches,

managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to

conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of

kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Programs and/or being

transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The

applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Programs. I

hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the

applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or

treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss,

cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or

lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above

waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this

document may not be altered in any manner and that any alternation without the express written consent from the Illinois Youth Soccer Association

will cause the participant to be removed from the Program. (revised 7/14/06)

Parents/Guardians Signature__________________________________________________ Date_____________________

(Parents/Guardians’ Signature is required if participant is under the age of 18)

Participant’s Signature_______________________________________________________ Date_____________________

(Participant’s Signature is required)

NOTE: ATTACH COPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO EXPEDITE MEDICAL TREATMENT.