MEDICAL RELEASE
In the event of an accident, injury, of sickness with respect to the undersigned participant, the undersigned parent gives his/her authority to the coach listed below to oversee the medical treatment until such time as the undersigned parent can be contacted. The undersigned parent also assumes responsibility for payment of any and all medical treatment provided to the undersigned participant.
Participant_______________________________________________________________________________
Parent/Guardian ( Please Print )______________________________________________________________
Adress___________________________________________________________________________________
Home Phone_______________________________ Cell Phone____________________________________
Insurance Company_____________________________________ Policy No:_________________________
Participant’s Physician______________________________________________________________________
Physicians Phone_______________________________________
Participant’s Known Allergies/Medical Conditions_______________________________________________
In case a parent/guardian cannot be reached, the following is designated to oversee the medical treatment until such time as a parent/guardian can be contacted.
Coach:__________________________________________ Number ____________________________
GENERAL RELEASE
I hereby acknowledge that the participation in soccer competition carries with it a potential risk of harm. Accordingly, in consideration of my being permitted to participate in the Panther 3v3 and Goalie Wars Soccer Tournament, I hereby release the Plainfield Soccer Club, Plainfield Shepard Hill School and Plainfield High School, the Tournament officials, the Sponsors, the officers, directors, commissioners, servants, agents and employees of the foregoing from any, and all claims or other liability for injury to person or property arising out of participation in the Panther 3v3 and Goalie Wars Tournament.
Insurance Carrier and Policy # _________________________________________________________________________
Participant’s Signature Date of birth____________________________________________________________________
Signature of parent/guardian:_________________________________________________________________________
Date Signed _____________________
Signed forms must be present at time of team registration.
In the event of an accident, injury, of sickness with respect to the undersigned participant, the undersigned parent gives his/her authority to the coach listed below to oversee the medical treatment until such time as the undersigned parent can be contacted. The undersigned parent also assumes responsibility for payment of any and all medical treatment provided to the undersigned participant.
Participant_______________________________________________________________________________
Parent/Guardian ( Please Print )______________________________________________________________
Adress___________________________________________________________________________________
Home Phone_______________________________ Cell Phone____________________________________
Insurance Company_____________________________________ Policy No:_________________________
Participant’s Physician______________________________________________________________________
Physicians Phone_______________________________________
Participant’s Known Allergies/Medical Conditions_______________________________________________
In case a parent/guardian cannot be reached, the following is designated to oversee the medical treatment until such time as a parent/guardian can be contacted.
Coach:__________________________________________ Number ____________________________
GENERAL RELEASE
I hereby acknowledge that the participation in soccer competition carries with it a potential risk of harm. Accordingly, in consideration of my being permitted to participate in the Panther 3v3 and Goalie Wars Soccer Tournament, I hereby release the Plainfield Soccer Club, Plainfield Shepard Hill School and Plainfield High School, the Tournament officials, the Sponsors, the officers, directors, commissioners, servants, agents and employees of the foregoing from any, and all claims or other liability for injury to person or property arising out of participation in the Panther 3v3 and Goalie Wars Tournament.
Insurance Carrier and Policy # _________________________________________________________________________
Participant’s Signature Date of birth____________________________________________________________________
Signature of parent/guardian:_________________________________________________________________________
Date Signed _____________________
Signed forms must be present at time of team registration.