Name: _____________________________________ Team Age:
_________ Girl or Boy
(circle one).
Social Security Number: _____________________________ Birth Date:___________________________
Sizes: (S, M, L, XL)Jersey:_________Shorts:________Parent
E-Mail______________________________
Address:
__________________________________________City/State:
_________ Zip: _____________
Home Phone: _______________Parent's Name & Work
Phone:__________________________________
Father's Name: ________________________Mother's Name:
____________________________________
Insurance Company Name &
Address:_______________________________________________________
Insurance Policy #: ________________________
Group#:___________ Date
of last tetanus shot: ______
Player's Primary Care Physician's
Name:_____________________________________________________
Physician's Address:
__________________________________________ Phone #:___________________
Known Allergies or other Medical
Problems:___________________________________________________
PARENT'S APPROVAL AND MEDICAL RELEASE:
RECOGNIZING THE POSSIBILITY OF PHYSICAL INJURY ASSOCIATED WITH SOCCER AND IN
CONSIDERATION FOR THE JR. IRISH SOCCER CLUB AND IT'S AFFILIATES ACCEPTING THE
REGISTRANT FOR IT'S SOCCER PROGRAMS AND ACTIVITIES (THE "PROGRAMS"), I
HEREBY RELEASE, DISCHARGE AND/OR OTHERWISE INDEMNIFY THE JR. IRISH SOCCER CLUB,
IT'S AFFILIATED ORGANIZATIONS AND SPONSORS, THEIR EMPLOYEES AND ASSOCIATED
PERSONNEL, ORGANIZATIONS AND SPONSORS, THEIR EMPLOYEES AND ASSOCIATED PERSONNEL,
INCLUDING THE OWNERS OF FIELDS AND FACILITIES UTILIZED FOR THE PROGRAMS AGAINST
ANY CLAIM BY OR ON BEHALF OF THE REGISTRANT AS A RESULT OF THE REGISTRANTS
PARTICIPATION IN THE PROGRAMS AND/OR BEING TRANSPORTED TO OR FROM THE SAME,
WHICH TRANSPORTATION I HERBY AUTHORIZE.
MY SON/DAUGHTER HAS RECEIVED A PHYSICAL EXAMINATION BY A PHYSICIAN AND HAS
BEEN FOUND PHYSICALLY CAPABLE OF PARTICIPATING IN THE PROGRAMS.
I REPRESENT THAT I AM GUARDIAN OF __________________________________________,
HEREINAFTER REFERRED TO AS "MY CHILD", A MEMBER OF A JR. IRISH SOCCER
CLUB SOCCER TEAM.
AS GUARDIAN OF MY CHILD AN WITH FULL AUTHORITY SO TO DO, I HEREBY DESIGNATE
______________________________________________, COACH
OR ________________________________________, MANAGER, AND EACH OF THEM, AS MY
ATTORNEY-IN-FACT TO OBTAIN MEDICAL TREATMENT AT MY EXPENSE FOR MY CHILD.
THE AUTHORITY HEREBY CONFERRED MAY BE EXERCISED BY ONE OR MORE OF THE FOREGOING
NAMED INDIVIDUALS AND SHALL INCLUDE ALL OF THE POWER I POSSESS AS A NATURAL
GUARDIAN TO OBTAIN MEDICAL TREATMENT FOR MY CHILD.
THE POWER GRANTED HEREIN INCLUDES THE POWER TO OBTAIN TREATMENT FROM PHYSICIANS,
HOSPITALS AND OTHER HEALTH CARE PROVIDERS AND THE RIGHT TO TAKE ANY ACTION
WHICH, IN THE DISCRETION OF THE PERSON EXERCISING IT, SEEMS REASONABLE UNDER THE
CIRCUMSTANCES.
IN EXERCISING THE AUTHORITY GRANTED BY THIS INSTRUMENT, THE ATTORNEY-IN-FACT
SHALL EXERCISE HIS OR HER DISCRETION MAKING SUCH DECISIONS AS HE OR SHE DEEMS
ADVISABLE GIVING DUE CONSIDERATION TO MY CHILD'S MEDICAL NEEDS.
THIS GRANT OF AUTHORITY SHALL NOT CREATE AN OBLIGATION IN ANY PERSON TO OBTAIN
MEDICAL TREATMENT AND SHALL NOT IMPLY ANY LIABILITY TO SUCH PERSON FOR THE
FAILURE TO OBTAIN MEDICAL TREATMENT OR FOR ANY INJURIES SUSTAINED BY MY CHILD AS
A RESULT OF SUCH TREATMENT.
SIGNATURE OF PARENT/GUARDIAN
DATE
Subscribed and sworn to before me this __________________
day of
_______________________,
20___________
Notary Seal Mandatory
Here! ____
________________________Notary Public