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Hammer FC Medical and Liability Release Form

 

As the parent/legal guardian of (player's first and last name) _________________________, I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.
 
Date of Player’s Birth___________________     

Date of last Tetanus Booster _____________

Known allergies of this player, including any allergies to medicine: __________________________________________________________________________

Any other medical problems which should be noted:
__________________________________________________________________________

Name of Player's Physician __________________________________
Phone (         ) ___________________________________________

Name(s) of Parent/Guardian 1:  _________________________________________________
Address____________________________________________________________________

Phone (home)______________________________(cell)_____________________________

 

Name(s) of Parent/Guardian 2:  _________________________________________________
Address____________________________________________________________________

Phone (home)______________________________(cell)_____________________________

 

Person to notify if parent/guardian is unavailable___________________________________

Phone (home)______________________________(cell)____________________________

 

Person responsible for charges (if different from above)______________________________
Address____________________________________________________________________
Phone (home)_____________________________(cell)_______________________________

Insurance Carrier ___________________________

Policy Number______________________________

 
I/we, the undersigned, as parent(s) or guardian(s) of_______________________________, a minor, do hereby consent to his/her participation in all of Hammer Soccer Club activities, including and not limited to travel with a club affiliate.
 
I/we give permission for our child’s picture to be used on the Hammer website and other promotional materials. __________ (initials)
 
In signing this consent, I/we do forever RELEASE, acquit, discharge and covenant to hold harmless, Hammer Soccer Club, Hammer Training Academy, facilities used by Hammer Soccer Club, Hammer Training Academy and its successors, departments, officers, employees, servants, and agents, of and all actions, causes of actions, claims, demands, damages, costs, loss of services, expenses, and compensation on account of, or in any way growing out of, directly or indirectly, all known and unknown personal injuries which I/we may not or hereafter have as the parent(s) or guardian(s) of said minor, and also all claims or rights of actions or damages which said minor has or hereafter may acquire, either before, during or after his/her participation in all of Hammer Soccer Club, Hammer Training Academy and to INDEMNIFY, reimburse or make good to Hammer Soccer Club, Hammer Training Academy or its successors, departments, officers, employees, servants and agents any loss or damages or costs, including attorney’s fees, the Club or its representatives may have to pay if any litigation's arise from said minor’s participation in the said Hammer Soccer Club, Hammer Training Academy activities.
 
Signature of Parent/Guardian ________________________________________________


Date____________________