Health and Liability Waiver | Kinnect Volleyball

Health Waiver &

Liability Form

This form is to be carried to all sanctioned competitions and practices

USAV YOUTH & JUNIOR VOLLEYBALL PLAYER MEDICAL RELEASE

This must be completed and signed by both the player and his 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 agrees to the terms and conditions listed below.

Club Name

Team Name

Player First Name

Player Last Name

Player Email

Birth Date

Age

Gender

Male

Female

Primary Contact: Parent or Guardian

First Name

Last Name

Primary Phone

Secondary Phone

Street Address

City

Region/State/Province

Postal / Zip code

Secondary Contact:

Relationship to Participant

Parent/Gaurdian

Other

If Other

First Name

Last Name

Primary Phone

Secondary Phone

Primary Insurance Co.

Family Physician Name

Primary Group / Policy #

Physician Phone Number

Please list any medications currently being taken. If None, please write None.:

In the past 24 months, have you been tested diagnosed and/or treated for a concussion:

Yes

If yes, provide the date (months and year), who performed the testing/diagnosis/treatement and what was the outcome?

Please list any allergies. If None, please write None.

Please elaborate on any medical conditions of which we should be aware. If None, please write None.:

Participant Signature (regardless of age)

Select a date

, has my permission to participate in training, competition, events, activities

Participant

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 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

Relationship to participant

Select a date

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.

Parent/Guardian Signature

Select a date

I do not authorize emergency medical/dental care for my daughter/son.

Parent/Guardian Signature

Select a date

Liability Waive: Terms & Conditions

I agree to the Liability Waiver's terms & conditions.Liability Terms and Conditions

Thanks for submitting!