Roanoke Valley Youth Soccer Club, Inc. Medical Release Form

IMPORTANT PLEASE NOTE: This form must be notarized and imprinted with the Notary’s seal (the seal is required for all players attending tournaments.) Parents must sign this form in front of a notary.

As the parent/legal guardian of:

________________________________________________________________

I request that in my absence the above named 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.

Player Date of Birth: Month _______ Day _____ Year ____ Date of Last Tetanus Booster: ____________________

Known allergies of this players, including any allergies to medicine: ________________________________________

Any other medical problems which should be noted: ______________________________________________________

_____________________________________________________________________________________________________

Family Physician: ________________________________________________ Phone: ___________________________

Name of Parent/Guardian: ___________________________________________________________________________

Address: ___________________________________________________________________________________________

City: _____________________________ State: ____________________ Zip Code: _________________________

Father Phone #: Home: __________________ Work: __________________________ Cell: ____________________

Mother =Phone #: Home: ____________________ Work: ______________________ Cell: _____________________

Person Responsible for Charges (if different from above): _________________________________________________

Address: ___________________________________________________________________________________________

City: __________________________________ State: ________________ Zip Code: _________________________

Phone #: Home: ______________________ Work: ________________________ Cell: ________________________

Person to Notify if Parent/Guardian is Unavailable: ______________________________________________________

Phone #: Home: _______________________ Work: ________________________ Cell: _______________________

Insurance Carrier: _______________________________________________ Policy #: __________________________

Parent/Guardian Signature: x _______________________________________________ Date: ___________________

The foregoing instrument was acknowledged before me on the ________ day of ________, 200 __ in the COUNTY/CITY of ______________________, Virginia.

_____________________________________________________

(Notary Public)

Commission Expires ___________________________________

SEAL REQUIRED