TEMPLATE

# YOUTH & JUNIOR 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 confidential.

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

Club:	___________________________________________	Team Name:	_____________________________________
First Name:	______________	Last Name:	___________________	Birth Date:	____________	Age:	____	£ £ Male Female

Primary Contact: Parent or Guardian
Name:	_______________________________________________
Address:	____________________________________	City, State & Zip:	____________________________________________
Primary Phone:	_______________________________	Alternate Phone:	____________________________________________

Secondary Contact:	£ Parent/Guardian	£ Other	______________________________
Name:	_______________________________________________
Primary 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:	________________________________________________________________________
Please list any medications currently being taken:	____________________________________________________________________________________
In £ In £ the past 24 months, have you been tested, diagnosed and/or treated for a concussion: Yes No
If yes, provide the date (months and year), who performed the testing/diagnosing/treatment and what was the outcome:	_______________________________________________________
Please list any allergies (write NONE if no allergies):	__________________________________________________________________________________
Participant Signature:	___________________________________	Date:	__________________
(regardless of age):
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.
Parent/Guardian Signature:	_____________________________________________	Date:	____________
Relationship to Participant:	________________________________
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.
Parent/Guardian Signature:	_____________________________________	Date:	___________________

OR
I do not authorize emergency medical/dental care for my daughter/son.
Parent/Guardian Signature:	______________________________________	Date:	___________________