Medical Release 2009 - 2010

HBC SOCCER CLUB MEDICAL RELEASE FORM July 1, 2009 through August 31, 2010 AS PARENT OR LEGAL GUARDIAN OF (NAME 0F PLAYER) , I REQUEST IN MY ABSENCE, THE ABOVE NAMED PLAYER BE ADMITTED TO ANY HOSPITAL OR MEDICAL FACILITY FOR DIAGNOSIS AND TREATMENT AND TO BE TRANSPORTED TO SUCH FACILITIES. I REQUEST AND AUTHORIZE PHYSICIANS, DENTISTS, AND STAFF, DULY LICENSED AS DOCTORS OF MEDICINE OR DOCTORS OF DENTISTRY OR OTHER SUCH LICENSED TECHNICIANS OR NURSES, TO PERFORM ANY DIAGNOSTIC PROCEDURES, TREATMENT PROCEDURES, OPERATIVE PROCEDURES AND X-RAY TREATMENT OF THE ABOVE PLAYER. I HAVE NOT BEEN GIVEN A GUARANTEE AS TO THE RESULTS OF THE EXAMINATION OR TREATMENT. I AS THE PARENT OR LEGAL GUARDIAN ACKNOWLEDGE THAT THE PLAYER PLAYING WITH OR FOR ANY HBC CLUB OR AFFILLIATED TEAM IS WHOLLY VOLUNTARY ON THE PART OF THE PLAYER AND ME. FURTHER I ACKOWLEDGE THAT I ASSUME FULL RESPONSIBILITY FOR ANY AND ALL PAYMENTS OF THE MEDICAL OR DENTAL PROCEDURES OR TREATMENT AND THE EMERGENCY TRANSPORTATION REQUIRED IN THE EVENT OF AN ACCIDENT, INJURY, SICKNESS, ETC. PLAYER’S BIRTH DATE:

S.S.N. #:

DATE OF LAST TETANUS BOOSTER (if known):

KNOWN ALLERGIES (INCLUDE MEDICINE): KNOWN MEDICAL PROBLEMS: PHYSICIAN:

DENTIST:

ADDRESS:

PHONE:

(

)

(

PARENT/GUARDIAN:

)

PHONE: (

)

(

)

(

)

(

)

(

)

ADDRESS:

(home) (cell) (other)

RESPONSIBLE PERSON FOR PAYMENT OF BILLS AND FEES: (if different from above) NAME:

PHONE:

(home)

ADDRESS:

INSURANCE CARRIER:

POLICY #:

(other)

GROUP #:

PERSON TO NOTIFY IF PARENT/GUARDIAN IS UNAVAILABLE:

(name)

(home phone)

(cell or work phone)

(name)

(home phone)

(cell or work phone)

CONTINUED ON BACK…

MEDICAL RELEASE FORM Recognizing the possibility of physical injury associated with soccer and in consideration for USYS/USS and its affiliates accepting the registrant for its soccer programs and activities (the “Programs”) I hereby release, discharge and/or otherwise indemnify USYS/USS including any USYS/USS affiliated host Soccer Club; The Sachem Youth Soccer League and Stony Brook Travel Soccer Club as hosts of the Long Island Soccer Shootout; The HBC Soccer Club; The Commack Soccer Club; MAPS/MSSL/NSCAA and their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant’s participation in the Program’s and/or being transported to or from the same, which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in the Programs.

I CERTIFY THAT I HAVE READ AND AGREE TO ALL THE TERMS ON BOTH THE FRONT AND BACK OF THIS FORM AND THAT ALL STATEMENTS ON MY BEHALF ARE TRUE. Therefore, I grant the following coaches and assistant coaches’ permission to act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or dentistry. I also assume the financial responsibility for any medical treatment for my child.

TEAM:

H.B.C. Hawks

AGE GROUP:

BU-17

COACH:

Adam Okula

PHONE:

631-271-7930

COACH:

Peg Franko

PHONE:

631-261-1101

COACH:

Joe Catarino

PHONE:

631-673-1958

COACH:

Bob Szilagy

PHONE:

631-424-8311

SIGNATURE OF PARENT/ GUARDIAN:

SUBSCRIBED AND SWORN TO ME THIS

DATE:

DAY OF

, 20

________________________________ (Notary public)