Player Medical Release Form (Adults)

To be executed by Participants over the age of majority

Player's Medical Conditions

Allergies/Asthma/Medications

List all known confirmed allergies to the following

Do you have 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 any condition?

Yes

Has a doctor prescribed an inhaler for Asthma?

Yes

Do you carry this inhaler with you?

Yes

Has a doctor prescribed an inhaler for any other reason?

Yes

Dietary Restrictions

What prescribed medication(s) should you carry with you?

Does you wear medical alert identification (e.g. bracelet)?

Yes

Do you have any other relevant medical condition that will require modification of programs?

Yes

If yes, please explain

Do you have any other conditions (e.g. anxiety), which we should be aware of?

Yes

If yes, please explain

Player’s Family Physician Name

Physician Phone Number

EMERGENCY CONTACT INFORMATION

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

I have 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 I have 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 me with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

PARTICIPANT SIGNATURE

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Player Medical Release Form (Adults)

To be executed by Participants over the age of majority

Player's Medical Conditions

Allergies/Asthma/Medications

List all known confirmed allergies to the following

Do you have 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 any condition?

Yes

Has a doctor prescribed an inhaler for Asthma?

Yes

Do you carry this inhaler with you?

Yes

Has a doctor prescribed an inhaler for any other reason?

Yes

Dietary Restrictions

What prescribed medication(s) should you carry with you?

Does you wear medical alert identification (e.g. bracelet)?

Yes

Do you have any other relevant medical condition that will require modification of programs?

Yes

If yes, please explain

Do you have any other conditions (e.g. anxiety), which we should be aware of?

Yes

If yes, please explain

Player’s Family Physician Name

Physician Phone Number

EMERGENCY CONTACT INFORMATION

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

PARTICIPANT SIGNATURE

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