THIS FORM IS TO BE CARRIED TO ALL SANCTIONED COMPETITIONS & PRACTICES.
2019/2020 Season
Revised 6/22/2019
USAV 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:
Male Female
First Name
Last Name
Birth Date
Age
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 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:
If None, please write None.
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.
Signature:
Date:
Parent/Guardian
or
I do not authorize emergency medical/dental care for my daughter/son.
Signature:
Date:
Parent/Guardian
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