Player Medical Release Form - Join the Illinois Performance Volleyball family!

Ahletes Name *

Age Group *

12U...15U...

Birthday *

Primary Contact : Parent or Guardian *

Primary Phone *

Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Contact: Parent/Guardian or Other *

Primary Phone & Address if different *

Primary Insurance Company & Primary Group Policy # *

Physician Name & Phone # *

Enter any medical conditions that we should be aware of including allergies. Enter any medications currently being taken. *

Has the athlete been tested, diagnosed or treated for a concussion in the past 24 months. If yes, provide month/year. *

I grant my athlete permission to participate in training, competition, events, activities and travel sponsored by USA Volleyball or any of its Regional Volleyball Associations (RVAs). I approve of the leaders who will be in charge of this program. I recognize that the 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. *

Yes
No

If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company. *

Yes
No

Enter Parent/Guardian Name & Date that permission is granted. *