Medical Waiver Child Name * First Name Last Name DOB * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Parent 1 First Name Last Name Phone 1 (###) ### #### Email 1 Parent 2 First Name Last Name Phone 2 (###) ### #### Email 2 In an emergency, when parent/guardian cannot be reached, please contact: Please list player allergies. Please list other medical conditions. Insurance Company Insurance Address Group Number Policy Number Medical Waiver * As parent/guardian of the above player(s), I certify that he/she is in excellent health and has no physical, mental or emotional problems that are likely to prevent participation in strenuous physical play at SWEAT FOOTBALL CLUB practices. I agree to hold harmless SWEAT FOOTBALL CLUB and its coaches/volunteers. l hereby release them from all liability on account of injuries sustained by player(s) while participating in soccer class activities. I give permission for player(s) to be medically treated for illness occurring or injury sustained during such participation and certify that he/she is covered by medical insurance which will reimburse the Soccer Club for expenses incurred by them, their agents and employees on account of medical treatment ordered at their discretion and also to indemnify them for any expenses not reimbursed by such insurance. I give consent for player(s) to be photographed, videotaped, or filmed while participating in Club activities, and for the resulting photos to be used by SWEAT FOOTBALL CLUB for educational and promotional purposes. I have read and understand the above. Date * MM DD YYYY Thank you!
