PLAYER MEDICAL RELEASE FORM
This must be completed - legibly - and signed in all areas by the player’s parent or guardian.
By signing this form the signee affirms having read it.
Name:___________________________________________________________________________________________
Last First Birth Date Age Gender
Phone:________________________ Email Address:_____________________________________________________
Primary Contact: Parent or Guardian
Name:_________________________________ Address:___________________________________________________
Phone:________________ Alternate Phone:__________________ Email Address:______________________________
Secondary Contact: ____Parent/Guardian ____Other
Name:_______________________________________
Phone:________________ Alternate Phone:__________________ Email Address:____________________________
Primary Insurance Co.:____________________________ Primary Group/Policy #:____________________________
Family Physician Name:________________________________ Physician Phone:_____________________________
Please elaborate on any medical conditions of which we should be aware:
Any medications currently being taken:
Any allergies:
If None, please write None.
Participant, ___________________________________ ________________, has my permission to participate in training,
competition, events, and activities relating to The Blast Volleyball Academy programs. 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 also certify to the best of my knowledge that the participant
named hereon is physically fit to engage in the activities described above.
May we administer to ________________________________: Acetaminophen (Generic Tylenol): NO YES
Participant Ibuprofen (Generic Advil): NO YES
Signed:______________________________________________ Relationship:_________________ Date:____________
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.
Signed:__________________________________________________________________________ Date:____________
Parent or Guardian
or
I do not authorize emergency medical/dental care for my daughter/son.
Signed:__________________________________________________________________________ Date:____________
Parent or Guardian