Advance Volleyball Medical 

    History, Release & Waiver Forms

                  Before Athlete may participate, complete document. Please Print and Sign.

Athlete Info

 

Name(Last)__________________________________  First___________________________Gender (M/F)______

 

Social Security #____________________________      Birth Date(mm/dd/yy)______________    Age___________

 

Current Grade (Circle)     2  3  4  5  6  7  8  9  10  11  12           School ________________________________________

 

Players Position(Check all that Apply)  ____  Setter    ____ Libero    _____ Defensive Specialist   _____ Middle Hitter

                                                                   ____Utility Player (All positions)  _____ Outside Hitter  _____  Opposite  Hitter

 

Parent and/or Guardian Info

 

Name:___________________________________  Address: ___________________________________________

 

Home Phone: (______)_________________________ City:______________________________ Zip: __________

 

Work Phone: (______)_________________________ Cell Phone: (______)_______________________________

 

In Case of Emergency - Contact

 

Name:____________________________ Phone #: (_____)_______________2nd Phone # (____)_____________

 

Permission to Play

 

Participant, _______________________________, has my permission to participate in training, competition, events and activities associated with the Advance Volleyball Program 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 on page 2. 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 ____________________________ Date (mm/dd/yy) _____________ Relationship _____________

 

Waiver Section

I Acknowledge that volleyball or any sporting event is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury, or property loss. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THE ADVANCE VOLLEYBALL PROGRAM.

I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death or personal injury or damages of any kind, which arise out of or relate to my participation in, or my traveling to and from the volleyball event, THE FOLLOWING PERSONS OR ENTITIES: The Parks & Recreation Department, The City of Lorain and Elyria, The Advance Volleyball Program Directors, The Program Directors, Sponsors; and the officers, directors, employees, representatives, and agents of any of the above; b) I AGREE NOT TO SUE any of the persons or entitles mentioned above for any of the claims or liabilities that I have waived, released or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

The undersigned,  (Guardian) _________________________________________ the parent and natural guardian of legal

guardian of (Minor's Name/Athlete) __________________________________________ hereby executed the foregoing Waiver and Release for and on behalf of the minor named herein. I hereby bind myself, the minor and all other assigns to the terms of the Waiver and Release. I represent that I have legal capacity and authority to act for and on behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release.

 

       Waiver & Release Forms           _________________________

                                                                                                        Player's Name   

Emergency Release Form Section 

If, during the course of my child's (athlete/participant) activities in volleyball and training, if they should become ill or sustain an injury, I hereby authorize the club directors, instructors and coaches affiliated with Advance Volleyball Program to obtain emergency medical/dental care.

 I will assume financial responsibility for the bills incurred through my

Insurance Company: __________________________________________________________________

 Parent and/or Guardian _________________________ Date (mm/dd/yy) __________________________

 I DO NOT authorize emergency medical/dental care for my daughter / son.

 Parent and/or Guardian ___________________________ Date (mm/dd/yy) ________________________

 State special instructions to follow in case of Emergency:________________________________________

 ___________________________________________________________________________________

 Athlete's / Participant's Medical and Health History

 

1) Primary Insurance Company: _____________________________________________________________

 

2) Family Physician Name:___________________________ Physician Phone:(______)________________

 

3) Height ______ Weight_______ Tetanus_________Polio ________ Measles (Rubella) _________

 

4) Is participant allergic to any medications if injury should occur and has to be treated? NO _____ YES ____

 

If YES name Allergic Medication (s) ________________________________________________________

_________________________________________________________________________________________

 

5)                      YES     NO       DATE          PLEASE Explain any Conditions OR medications needed.

5a) Allergies     ____   ____  ___________  ___________________________________________________

5b) Asthma       ____   ____  ___________  ___________________________________________________

5c) Congenital  ____   ____  ___________  ___________________________________________________

5d) Diabetes      ____   ____  ___________  ___________________________________________________

5e) Epilepsy      ____   ____  ___________  ___________________________________________________

5f) Heart            ____   ____  ___________  ___________________________________________________

6) Any Joint injuries (Ankle, Knee, Back, Neck, Wrist, Elbow, etc.) NO _____ YES _____ If Yes, Please state

the type, location, and date of injury and conditions: _____________________________________________

________________________________________________________________________________________

 

7) Any psychosocial or physical condition the participant is currently under professional care: NO___ YES___

If Yes ________________________________________________________________________________

 

8) Is the participant currently taking any medications? NO ____ YES ____ If Yes, State the name of 

the drug(s), dosage and frequency needed: ____________________________________________________

 

9) Any Injuries in the past 2 months or medical conditions we should be aware of _____________________