Form Medical

Medical Release Form

Make a Selection:

Player Information:

First Name: Last Name: Sex: MF Birthday: MM/DD/YYYY Phone: E-mail: Street Address: Apartment: City: State: Zip:

Health History:

Seizure Disorder Asthma Allergy Orthopedic Injuries or Disorder: Drug Sensitivity or Allergy: Chronic Medical Problems: Other Special Problems:

Medical Information:

Name of Family Physician: Phone: Medical Insurance Company: Policy Number:

In Case of Emergency Contact:

Name: Relationship to Player: Day Phone: Evening Phone:

Parent or Legal Guardian should complete the following:
I hereby certify that the above - mentioned Player is in good health and fully able to participate in all the activities Skill Check Soccer. I agree that Skillz Check Soccer and its directors will not be held responsible for any accident or loss to the participant however caused and hereby release Skillz Check Soccer from all claims or damages which may arise from any accident or loss.
I consent to have administrators of Skillz Check Soccer act on my behalf should any emergency arise, and hereby grand permission to said adminstrators to authorise medical attnetion recommended by a physician, nurse or hospital.

Full Name of Parent or Legal Guardian:

Date: / /

Refund Policy: No cash refunds; You will receive a credit for a future clinic