Florida Medical History And Release Form For Player Preview
Microsoft Word - AAU MEDICAL RELEASE.doc
FLORIDA AAU VOLLEYBALL PROGRAM
MEDICAL HISTORY AND RELEASE FORM
This form must be carried with the coach during all training and competitions. Please complete all sections of this form. Both the player and his or her parent/guardian must sign in all appropriate areas. By signing this form, the participant and parent/guardian affirms they have read and understand it.
LAST NAME FIRST NAME MI
(CIRCLE ONE) M F
CITY STATE ZIP CODE
SOCIAL SECURITY NO.
AAU MEMBERSHIPS NO.
TEAM NAME DIVISION HEIGHT WEIGHT
The Participant,, has permission to participate in the AAU Junior National Volleyball Program. I certify that the participant has full medical insurance with the company listed below and is physically fit to engage in the activities of the program. I approve the leaders and coaches of this program and recognize that they will serve to the best of their ability.
MUST SIGN: Date:
MUST SIGN: Relationship:
STREET ADDRESS CITY STATE ZIP
DOES THIS POLICY COVER SPORTS RELATED ACCIDENTS?
INSURANCE COMPANY GROUP POLICY # (CIRCLE ONE) YES NO
If my son or daughter should become ill or sustain an injury during his or her activities of the volleyball program, I hereby authorize you to obtain emergency medical/dental care.
I do not authorize emergency medical/dental care for my son or daughter.
YES OR NO
IMMUNIZATIONS (please state month and year):
Tetanus Polio Measles (Rubella) Is the participant taking any medications?NOYES
If yes, please name the drug(s), dosage and frequency needed:
Is there any psycho-social or physical condition for which the participant is currently under professional care?
Please list any injuries the participant has suffered in the last two months: Elaborate on any other medical conditions:
STATE OF COUNTY OF
SWORN TO BEFORE ME, A NOTARY REPUBLIC, BY SAIDPERSONALLY KNOW TO ME THISDAY OF ,19 .
NOTARY REPUBLIC MY COMMISSION EXPIRES
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