OAVB - MEDICAL RELEASE FORM

MEDICAL RELEASE FORM
This must be completed legibly and signed in all areas by both the player and 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.
Email to receive copy of Release Form*
example@example.com
Club
Team Name*
Participant Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Age*
Male/Female?

MaleFemale
Primary Contact

Parent or Guardian
Name*
Address*

Address

Street Address Line 2

City, State & ZipState / Province

Postal / Zip Code
Primary Phone*
Please enter a valid phone number
Alternate Phone
Secondary Contact
Type a question

Parent/GuardianOther
If Other, enter Relationship
Name
Primary Phone
Alternate Phone
Insurance Information
Primary Insurance Co
Primary Group/Policy#
Family Physician Name
Physician Phone
Medical Conditions
Please list any medications currently being taken;
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:*

YesNo
If yes, provide the date (months and year), who performed the testing/diagnosing/treatment and the outcome:
If none, type N/A
Please list any allergies:
Type NONE of no allergies
Participant Signature (regardless of age)*

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Date*

MonthDayYear
Date
Participant, {name} , 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*

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Date*

MonthDayYear
Date
Relationship to Participant*
Authorization to Seek Medical Care

Please sign below to AUTHORIZE or DO NOT AUTHORIZE
If, during the course of participant's activities in volleyball, they 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 for Authroization

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Date

MonthDayYear
Date
I do not authorize emergency medical/dental care.
Parent/Guardian Signature

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Date

MonthDayYear
Date
Should be Empty:

MEDICAL RELEASE FORM

Primary Contact

Secondary Contact

Insurance Information

Medical Conditions

Authorization to Seek Medical Care