Medical Release/Emergency Contact
Email address *
REGIONAL CUP TOURNAMENT Emergency Information and Medical Release
Player's First and Last Name
Your answer
Full Address: Street, City, State, and Zip APT#
Your answer
Parent/Legal Guardian
Your answer
Players DOB
Your answer
Age
Your answer
American Citizen?
Team Name:
Your answer
Team State:
Your answer
Emergency Contact #1 Phone Number
Your answer
Relation to Player
Your answer
Emergency Contact #2 Phone Number
Your answer
Relation to Player
Your answer
Players Physician and Physician Phone Number
Your answer
Insurance Company and Policy Number
Your answer
ANY Known Allergies or Allergic Reactions to Medicine?
Your answer
ANY Known Medical Concerns?
Your answer
PARENTAL CONSENT AND INDEMNIFICATION AGREEMENT I, the minor’s parent and/or legal guardian authorize and consent to medical,surgical and hospital care, treatment and procedures to be performed by available medical staff and/or a licensed physician when deemed necessary or advisable by appointed representatives in case of my absence. I waive my right of informed consent to such treatment and release from any litigation expenses, attorney fees, loss liability, and damage orcost any Releases may incur as the result of any such claim. I further understand that my electronic submission is the same as a signature and agree to the electronic consent.
Parent/Legal Guardian's Electronic Signature
Your answer
Player's Electronic Signature
Your answer
Date
MM
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DD
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YYYY
Time
Time
:
A copy of your responses will be emailed to the address you provided.
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