MidSouth Futbol Club 2014-2015 Medical Release Medical Release – Insurance Information June 1, 2014 through August 31, 2015 PLEASE PRINT CLEARLY! 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: 1. 2. 3. 4. 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 child. 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: (______) _______________________ EMERGENCY PERSONS (OTHER THAN PARENTS) 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.
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