MidSouth Futbol Club 2014

MidSouth Futbol Club
2014-2015 Medical Release
Medical Release – Insurance Information
June 1, 2014 through August 31, 2015
KNOW ALL MEN BY THESE PRESENTS, that I ____________________________________________________________________ being the parent/
guardian of (print full name)__________________________________________________________________, born ____/_____/_________ hereby give my
consent for him/ her to represent the MidSouth Futbol Club in their soccer program for the seasonal year of June 1, 2014 through
August 31, 2015. And desiring to execute a SPECIAL POWER OF ATTORNEY, have made, and appointed the team coach
____________________________, the team manager, _________________________________ and a team parent, ____________________________ my
Attorney(s)-in-Fact to act as follows: GIVING & GRANTING unto my said Attorney(s)-in-Fact full power to, if necessary:
Provide MEDICAL and HOSPITAL CARE FOR THE ABOVE PLAYER I authorize my consent for any and all medical and hospital care and
treatment, deemed necessary by athletic trainer, duly licensed physician &/or dentist, for health and well-being of my above named
Provide TRAVEL I authorize transportation convenient or necessary to and from any athletic event or social event connected with this
team or club.
Provide assistance in attending ATHLETIC and SOCIAL FUNCTIONS I authorize assistance in providing convenient or necessary
arrangements for my child’s participation or attendance at athletic and social function for this team or club.
FURTHER AUTHORIZATIONS I authorize the performance of all necessary acts in the execution of the aforesaid authorization with the
same validity as I could effect if personally present. Any act lawfully done by my said Attorney(s)-in-Fact shall be binding on the hired
legal and personal representatives and myself.
In consideration for the performance of any or all of the functions authorized in the paragraphs one through four above, on my
behalf and for the benefit of my child and recognizing the possibility of physical injury associated with soccer, I hereby agree to
assume the risk and hold harmless, release, discharge and/or otherwise indemnify the MidSouth Futbol Club, and their affiliated
organizations and sponsors, their employees and associated personnel including my Attorney(s)-in-Fact, the owners of the fields
and facilities utilized for the programs, against any claim by on behalf of the registrant from any liability for negligence in the
performance of said functions. However, this shall not apply to willful or wanton misconduct affecting my child.
PLAYERS ADDRESS:_______________________________________________________________ CITY:_____________________ ST:________ ZIP_____________
FATHER:_______________________________________________ HM PH: (______) _______________________ WK PH: (______) _______________________
CELL PH: (______) _______________________
MOTHER:_______________________________________________ HM PH: (______) _______________________ WK PH: (______) _______________________
CELL PH: (______) _______________________
NAME:_____________________________________________________ RELATIONSHIP_________________________ HM PH: (______) ______________________
HER WORK: (______) _________________________ HER CELL: (______) _______________________
HIS WORK: (______) _________________________ HIS CELL: (______) _______________________
ADDRESS:_______________________________________________________________ CITY:_____________________ ST:________ ZIP_____________
FAMILY INSURANCE CARRIER: POLICY #______________________________________ GROUP #_______________________________________
INSURANCE NAME: _________________________________________________________________________ PHONE (______) _______________________
PHYSICIAN’S NAME_________________________________________________________________ PHONE (______) ________________________________
GROUP/ OFFICE NAME: _____________________________________________________________ NIGHT PHONE (______) _______________________
Signature of Parent/ Guardian: _______________________________________________________________ Date: _____________________________
Notary: Subscribed and sworn to before me on this ______________ day of ____________________, 20 ________.
___________________________________________________________________________ Seal:
(Signature of notary)
Copy the physician’s certificate onto the back of this form.
Be sure any medical problems, allergies, and/ or medications are listed on the certificate.