Fillable Printable Medical Waiver Form - Virginia

Medical Waiver Form - Virginia

VYSA MEDICAL RELEASE FORM

As the parent/legal guardian of _______________________________________, born _______________________

I hereby give my consent and permission for the player named below to be medically and/or

surgically treated for injuries and/or illness of any kind or seriousness under the direction of

Team Officials with a valid USYS Member Pass, until such time as I can be contacted. Further, I

give my consent and permission to the physician and/or hospital and/or other health care

provider selected to provide medical or surgical treatment, including, without limitation, dental

care, hospitalization, injection, anesthesia, invasive surgery or any other form or kind of medical

or surgical care (emergency or otherwise) for the player.

Known allergies of this player, including any allergies to medicine

_______________________________________________________________________________________________________

Family Physician: __________________________________ Phone: ( ) _______________

Name of Parent/Guardian __________________________________________

Address: _______________________________________________________

City/State/Zip Code: _____________________________________________

Phone: (H) _______________________ (Cell Phone) _________________________

Person to notify if parent/guardian is unavailable: __________________________________

Phone: ___________________________________________________________________

Insurance Carrier: ____________________________ Group Number: _______________________

Signature of Parent/Guardian _________________________________________________________

Sworn to and subscribed before me on the _____ day of ________________, _______

Notary Public in and for the State of ___________________

Notary Name _________________________________________________________________

My commission Expires ______________________