OCTOBER
7 & 8, 2006
GENERAL RELEASE
This form must
be in the possession of the team’s coach or representative
at all times throughout the tournament weekend.
In registering my
child as a participant in the Newton Girls Soccer Columbus Day Invitational Tournament, I understand that my child
and I assume any and all risks which might be associated with this activity,
and waive and release all rights and claims which my child, heirs, executors,
administrators, assigns or I may have against the Newton Girls Soccer, its
directors, coaches, officials, or representatives for any and all injuries or
damages of any kind suffered as a result of participation in the NGS Columbus
Day Invitational Tournament.
►
Signature of
parent/guardian:
_______________________________________________________________
Team
(Town/Age Group):
_____________________________________ Date:_____________________________
MEDICAL RELEASE FORM
As the parent/legal
guardian of _______________________________________, I request that in my
absence the above-named player be admitted to any hospital or medical facility
for diagnosis and treatment. 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 minor. I have not been given a guarantee as to the
results of examination or treatment. I
authorize the hospital or medical facility to dispose of any specimen or tissue
taken from the above-named player.
Date
of player’s birth_____/_____/_____ Date
of last Tetanus Booster_____/_____/_____
Month Day
Year Month Day
Year
Known allergies of
this player, including any allergies to
medicine________________________________________
____________________________________________________________________________________________
Any other medical
problems which should be noted
___________________________________________________
____________________________________________________________________________________________
Family
Physician_________________________________________ Phone
(_____)________-________________
Name of
Parent/Guardian________________________________________________________________________
Address______________________________________________________________________________________
City/State/Zip
_________________________________________________________________________________
Phone_____________________________
Insurance
Carrier_________________________________________ Policy Number_________________________
►
Signature of Parent/Guardian____________________________________________________________________
FORM P15 -