Bridge by the Water

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.

Gender

Primary Contact: Parent or Guardian

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Secondary Contact: 

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

, 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  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.

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.

OR

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

Thanks for submitting!