Fillable Printable Youth and Junior Volleyball Player Medical Release Form

Youth and Junior Volleyball Player Medical Release Form

FORM IS TO BE CARRIED TOALL SANCTIONED COMPETITIONS & PRACTICES.

2014-2015 USAV YOUTH & JUNIOR VOLLEYBALL PLAYER

MEDICAL RELEASE FORM

This must becompleted - legibly - and signedin all areas by both the player and his/her parent or guardian.I understand and agree that this

document will be keptinthe possession of authorized adult team personnel and that reasonable care will be usedtokeep this information

confidential. By signing this form the participant affirms having read and agreed to the terms and conditions listed below.

Club:

TeamName:

MaleFemale

First Name Last Name Birth Date Age

PrimaryContact: Parent orGuardian

Name:

Address:

City, State &Zip

PrimaryPhone: Alternate Phone:

PrimaryInsurance CoPrimaryGroup/Policy #

Family Physician Name Physician Phone

ParticipantSignatureDate:

(regardlessofage):

Participant,

, hasmypermission to participate in training,

competition, events, activities and travel sponsored by USA Volleyball or any ofits Regional Volleyball Associations (RVAs).I approve

of theleaders who will be in charge ofthis 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 inthe

possession of authorized adult team personnel and that reasonable care will be used tokeep this information confidential. I agree to

allow the authorized adult team personnel to release this information in the event ofa medical emergency toa third party medical

provider. I also certify to the best ofmyknowledge that the participant named hereon is physically fit to engage inthe activities

described above.

Parent/Guardian Signature:Date:

Relationship

toParticipant:

Revised 08/01/2013

Please elaborateon anymedical conditions of which weshould beaware:

Please list any medicationscurrently being taken:

Inthe past 24month, have you been tested, diagnosedand/ortreated for a concussion: Yes No

If yes,provide the date (months and year), who performed thetesting/diagnosing/treatmentandwhat was the outcome:

Please list any allergies:

IfNone, please write None.

If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain aninjury, I hereby authorize you

to obtain emergency medical/dentalcare. I will assume financial responsibility for the bills incurred through my insurance company.

Signature:

Date:

Parent/Guardian

I donotauthorize emergency medical/dental careformydaughter/son.

Signature:

Date:

Parent/Guardian

THIS