WORLDWIDE SOCCER, LLC MEDICAL AND LIABILITY RELEASE

WORLDWIDE SOCCER, LLC

MEDICAL AND LIABILITY RELEASE/BLARNEY BLAST 2023
As the parent/guardian of
Player Name
I request that in my absence, the above player be admitted to any hospital or medical 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 of 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.

Further, I hereby hold WorldWide Soccer LLC, its employees and its agents harmless from any and all liability resulting from any accident, illness, injuries or losses that my child may suffer while participating in any and all WorldWide Soccer, LLC events. I certify that my child is in good health and is able to participate in all activities. If any attention is required for illness or injury, I give permission to a staff member to provide such care. By signing below I give permission for my child to be photographed or videotaped and for those images to be used by World Wide Soccer, LLC for future promotions.
Birthdate of player*
Known allergies of this player, including any allergies to medicine*
Any other medical problems which should be noted*
Family Physician*
Phone*
Insurance Carrier*
Policy Number*
Name of Parent/Guardian*
Address*
Phone*
Person responsible for charges (if different from above)
Address
Phone
Person to notify if parent/guardian is unavailable*
Phone*
Signature of Parent/Guardian*

Clear
Should be Empty: