Player Medical Release Form (Minors)

To be executed by Participants under the age of majority

Player's Medical Conditions

Allergies/Asthma/Medications

List all known confirmed allergies to the following

Has your child/ward suffered any serious allergic or asthmatic reaction? If so, please provide details, including type and severity of reaction: Is allergy considered: mild OR moderate OR serious OR life threatening

Has a doctor prescribed an Epi-Pen for your child/ward

Yes

Has a doctor prescribed an inhaler for Asthma?

Yes

If yes, does the child carry this inhaler with them?

Yes

Has a doctor prescribed an inhaler for any other reason?

Yes

Dietary Restrictions

What prescribed medication(s) should your child/ward have WITH them?

Does your child/ward carry or wear a medical alert identification (e.g. bracelet)?

Yes

Does your child/ward have any other relevant medical condition that will require modification of programs?

Yes

If yes, please explain

Does your child/ward have any special fears or conditions (e.g. anxiety, sleepwalking), which staff should be made aware of in order to make programming more enjoyable/relaxed?n option

Yes

If yes, please explain

Player’s Family Physician Name

Physician Phone Number

EMERGENCY CONTACT INFORMATION

PARENT/GUARDIAN # 1 NAME

PARENT/GUARDIAN # 1 PHONE NUMBER

PARENT/GUARDIAN # 1 ALTERNATE PHONE NUMBER

PARENT/GUARDIAN # 2 NAME

PARENT/GUARDIAN # 2 PHONE NUMBER

PARENT/GUARDIAN # 2 ALTERNATE PHONE NUMBER

IN EMERGENCY, WHEN PARENTS CANNOT BE REACHED, PLEASE CONTACT:

Emergency Contact # 1 Name

Relationship to above-named player

Emergency Contact # 1 Phone Number

Emergency Contact # 2 Name

Relationship to above-named player

Emergency Contact # 2 Phone Number

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

My child 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 training, matches and any and all events run by Sigra Football Group.

I request and give permission, that in my absence, the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I give my consent to have an athletic trainer, licensed medical doctor, dentist or other such licensed technicians or nurses provide my child with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

PARENT/GUARDIAN NAME

SIGNATURE OF PARENT/GUARDIAN

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Player Medical Release Form (Minors)

To be executed by Participants under the age of majority

Player's Medical Conditions

Allergies/Asthma/Medications

List all known confirmed allergies to the following

Has a doctor prescribed an Epi-Pen for your child/ward

Yes

Has a doctor prescribed an inhaler for Asthma?

Yes

If yes, does the child carry this inhaler with them?

Yes

Has a doctor prescribed an inhaler for any other reason?

Yes

Dietary Restrictions

What prescribed medication(s) should your child/ward have WITH them?

Does your child/ward carry or wear a medical alert identification (e.g. bracelet)?

Yes

Does your child/ward have any other relevant medical condition that will require modification of programs?

Yes

If yes, please explain

Does your child/ward have any special fears or conditions (e.g. anxiety, sleepwalking), which staff should be made aware of in order to make programming more enjoyable/relaxed?n option

Yes

If yes, please explain

Player’s Family Physician Name

Physician Phone Number

EMERGENCY CONTACT INFORMATION

PARENT/GUARDIAN # 1 NAME

PARENT/GUARDIAN # 1 PHONE NUMBER

PARENT/GUARDIAN # 1 ALTERNATE PHONE NUMBER

PARENT/GUARDIAN # 2 NAME

PARENT/GUARDIAN # 2 PHONE NUMBER

PARENT/GUARDIAN # 2 ALTERNATE PHONE NUMBER

IN EMERGENCY, WHEN PARENTS CANNOT BE REACHED, PLEASE CONTACT:

Emergency Contact # 1 Name

Relationship to above-named player

Emergency Contact # 1 Phone Number

Emergency Contact # 2 Name

Relationship to above-named player

Emergency Contact # 2 Phone Number

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

PARENT/GUARDIAN NAME

SIGNATURE OF PARENT/GUARDIAN

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