Fillable Printable Medical Waiver Form - Ohio

Medical Waiver Form - Ohio

WAIVER OF LIABILITY FORM

AUTHORIZATION FOR MEDICAL AND/OR DENTAL TREATMENT FORM

As the parent/legal guardian of ____________________________________________, I request that in my absence the

above named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize

physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed

technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray

treatment of the above named minor. I have not been given a guarantee as to the results of examination or treatment. I

authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of Players Birth / __ / __ Date of last Tetanus Booster / / __ .

Month Day Year Month Day Year

Known allergies of this player, including any allergies to medicine___________________________________________

Any other medical problems which should be noted _____________________________________________________

Family Physician ___________________________________________ Phone ________________________________

Name of Parent/Guardian __________________________________________________________________________

Address ________________________________________________________________________________________

City/State/Zip ____________________________________________________________________________________

Phone (Home) ___________________ (Work) ______________________ (FAX)______________________________

Person responsible for charges (if different from above) ___________________________________________________

Address _________________________________________________________________________________________

City/State/Zip ____________________________________________________________________________________

Phone (Home) ___________________ (Work) ______________________ (FAX)______________________________

Person to notify if parent/guardian is unavailable ________________________________________________________

Phone (Home) _____________________ (Work) _______________________ (FAX)___________________________

Insurance Carrier________________________________________ Policy Number _____________________________

WAIVER OF LIABILITY

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of United States

Youth Soccer, (a.k.a. USYS), its affiliated organizations and sponsors. Recognizing the possibility of physical injury

associated with soccer and in consideration for USYS accepting the registrant for its soccer programs and activities (the

“Programs”), I hereby release, discharge and/or otherwise indemnify USYS, its affiliated organizations, and sponsors,

their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs,

against any and/or all claims by or on behalf of the registrant as a result of the registrant’s participation in the Programs

and/or being transported to or from the same, which transportation I hereby authorize.

KYSA 2/04 ease check our website for further updated information: WWW.KYSOCCER.NET or .ORG

Signature of Parent / Guardian _________________________________________________ Date _________________

NOTARY PUBLIC

STATE OF ____________________________, COUNTY OF ________________________

Sworn to and subscribed before me on the ___________ day of ___________, 20__________

Notary Public in and for the State of ______________________________________________

My Commission expires: ________________________________________________________ (Place notary seal above.)