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SSAAK Chugiak Soccer Club

PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

Player’s Name: ____________________________________Date of Birth: __________________________ Gender: ___________

Address: ________________________________________City: _______________________State: ___________    Zip: ________________

Email Address: _________________________________________________ 

EMERGENCY INFORMATION Father’s Name:___________________________________ Home Phone:____________________

Work Phone:____________________ Mother’s Name: _________________________________

Home Phone: ____________________Work Phone: ___________________

In an emergency, when parents cannot be reached, please contact:

Name: ____________________________________________Home Phone: ____________________

Work Phone: ____________________ Name: ____________________________________________

Home Phone: ____________________Work Phone: ____________________

Allergies: _________________________________________Past or Current Concussions and/or Head Injury History: _______ If yes to concussions or head injuries, please give dates and explain:

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Other Medical Conditions: _______________________________________________________________________________________________

Player’s Physician: __________________________________________

Physician’s Phone: ________________________________________

Medical and/or Hospital Insurance Company: _____________________________________Phone:____________________________

Policy Holder: __________________________________Policy #: ________________________________

Group #: ______________________

PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS FORM PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE Recognizing the possibility of injury or illness, and in consideration for  (SSAAK) Chugiak Soccer Club and members of (SSAAK) Chugiak Soccer Club accepting my son/daughter as a player in the soccer programs and activities of (SSAAK) Chugiak Soccer Club and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify (SSAAK) Chugiak Soccer Club, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.


Signature of Parent/Guardian _____________________________________________________________________________________ Date_________________


(Please Print Name)  Parent/Guardian ______________________________________________________________________________ Date _________________

Thank You For Taking The Time





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