Medical/Liability Release
As the parent/legal guardian
of ________________________________________________, I request that in my
absence the above named player be admitted to any hospital 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 on the above 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.
The player’s parents and/or legal guardians hereby consent
and agree the Indy Revolution Soccer Club, its officers, directors,
commissioners, coaches and other club officials (volunteer or professional),
and Glendale Soccer Club will not be liable for any injury sustained by the
Player while participating in any club activity; and that such entities and
persons have no responsibility for lost, stolen, or damaged property. In addition, I consent to the use of this
player’s photographic image by the Club for club-related marketing purposes.
Player’s date of birth
___/___/___ Date
of last Tetanus Booster ___/___/___
Known allergies, including any
allergies to medicine___________________________________________
List any known medical
problems __________________________________________________________
_____________________________________________________________________________________.
Family
Physician____________________________________ Phone (_____)_______________________
Name of Parent(s) or
Guardian(s)___________________________________________________________
Address
_________________________________________ City/State/Zip
__________________________
Phone (___)_____________
(H)
(___)_____________(W) (____)_____________
(Cell/Pager)
Person responsible for payment
of medical bills (if different from above)________________________________
Address
_________________________________________ City/State/Zip
__________________________
Phone (___)_____________
(H)
(___)_____________(W) (____)_____________
(Cell/Pager)
Emergency contact other than
parent or guardian ______________________________________________
Address
_________________________________________ City/State/Zip
__________________________
Phone (___)_____________
(H)
(___)_____________(W) (____)_____________
(Cell/Pager)
Insurance Carrier_____________________________________ Policy Number ________________
Signature of Parent or
Guardian____________________________________________________________
JURAT
STATE OF____________________
Sworn to and subscribed before me on the _____day of
_____________________, 2_________
__________________________________________________
Notary
Public in and for the State of ____________________
My
commission expires ___/___/, 2_____