2024-2025 USAV Medical Release

Youth & Junior Volleyball Player Medical Release Form

This must be completed - legibly - and signed in all areas by both the player and his/her 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.
Club:*
Team Name:*
Participant's Name*

First NameLast Name
Date of Birth*
mm/dd/yyyy
Age*
Gender*

MaleFemale
Primary Contact: Parent or Guardian *

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number *
Either Parent/Guardian or Adult Participant
Alternate Phone
Please enter a valid phone number.
Primary Email*
Either Parent/Guardian or Adult Paticipant
Secondary Contact*

Parent/ GuardianOther
Secondary Contact Name*

First NameLast Name
Secondary Contact Phone*
Please enter a valid phone number.
Alternate Phone
Please enter a valid phone number.
Primary Insurance Company*
Primary Insurance Group/ Policy # *
Family Physician Name:*
Physician Phone*
Please enter a valid phone number.
Please elaborate on ANY MEDICAL CONDITIONS of which we should be aware of If none, type NONE:*
Please list any medications currently being taken. If none, type "NONE":*
In the past 24 months, have you been tested, diagnosed and/or treated for a concussion:*

YesNo
If yes, provide the date (month and year), who performed the testing/diagnosing/treatment and what was the outcome:
Please list any allergies. If none, type "NONE"*
Participant Signature (regardless of age)*

Clear
Date*

MonthDayYear
Date
Permission to Participate
The above named participant has my permission to participate in training, competiton, events, activites 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 particpant has full medial 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 particpant named heron is physically fit to engage in the activites described above.
Parent/Guardian Signature*

Clear
Relationship to Participant*
Date Signed*

MonthDayYear
Date
Authorization to Treat
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.*

Yes, I authorize emergency medical/dental careNo, I do not authorize emergency medical/dental care
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Youth & Junior Volleyball Player Medical Release Form

Permission to Participate

Authorization to Treat