Medical Form

First Name

Birthday

Last Name

Street Address

Street Address Line 2

City

Postal / Zip code

Region/State/Province

Parent/Guardian

First Name

Relastionship

Last Name

Parent/Gaurden Phone

Street Address

Street Address Line 2

City

Region/State/Province

Postal / Zip code

Medical Issues

Please elaborate on any medical conditions we should be aware of

Please list any medications we should be aware of

Primary Insurance Information

Primary Insurance

Policy Number

Primary Physician

Primary Physician Phone Number

Acknowledgment I acknowledge that my child is in good mental and good physical condition. I accept the risks that are associated with my child when we/I decided to allow him/her to participate. I indemnify and hold them harmless from any injuries, demands, or death that may be sustained by my child. I authorize the organizers to take photos and videos of my child during the program and while on the premise. I allow them to use this for educational, advertising, and marketing purposes provided that they value our privacy with respect and will not associate it with unpleasant situations. I release the organizers from any liabilities, loss, damage, and fees during the program or while on the premise. The athlete stated above, has my permission to participate in training, competition, events, activities and travel sponsored by Spiker Beach Volleyball Club. I approve of the coaches/leaders who will be in charge of this program. I recognize that the coaches/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 adult team personnel and that reasonable care will be used to keep this information confidential. I agree to allow the authorized adult team 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.

Thanks for submitting!