Name:
Birth date:
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ZIP:
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Primary Insurance Co:
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Primary Physician Name:
Primary Physician Phone:
Medical Conditions:
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Allergies:
If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain an injury, I hearby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company. My child is in good health and able to participate in normal volleyball activities. Parent or Guardian Name:
OR
I do not authorize emergency medical/dental care for my daughter/son. Parent or Guardian Name:
The above athlete has my permission to participate in training, competition, events, activities, and travel sponsored by American Athlete and USA Michigan Volleyball. I approved 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 I(we) am(are) the parent(s) or legal guardians(s) of the athlete and that the participant has full medical insurance with the company listed above. I understand that all reasonable measures will be taken to safeguard the health and safety of my child. In consideration of my child's participation in this program, I do hereby release and forever discharge American Athlete and USA Michigan Volleball, the practice facility, its staff, officers, coaches, agents, employees, representatives and assigns, of and from any and all claims and demands of every kind, which my child may have or may hereafter acquire, for any and all damages, losses, or injuries which may be suffered or sustained by his/her connection with their activities and all such claims are hereby waived and released, and I covenant not to sue therefore. By signing this form the participant affirms having read it on 05/19/2012.
Participant Signature:
Parent or Guardian Signature:
