Parental Consent Form
The following form is used to provide information to aid in any event of a medical
emergency. Please fill out the form neatly and fully. PLEASE PRINT.
________________________________________________________________________________
Name
________________________________________________________________________________
Guardian's Name/Relationship
________________________________________________________________________________
Allergies
________________________________________________________________________________
Present Medications
________________________________________________________________________________
Relevant or Recent Illnesses or Injuries
EMERGENCY CONTACTS
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| Father's Name | Home Phone | Work Phone | |
________________________________________________________________________________
| Mother's Name | Home Phone | Work Phone | |
________________________________________________________________________________
| Other Contact/Relationship | Home Phone | Work Phone | |
________________________________________________________________________________
| Insurance Company | Group# | Policy# | Phone |
MEDICAL RELEASE
My child is in good health and has my permission to participate in goalkeeper training.
He/she has no previous illness or bodily injury which will keep him/her from participating
in the sport of soccer.
Participation in any sport may cause physical injury including sprains, strains, contusions,
fractures, dislocations, ruptures, herniations, lacerations, concussions and even death.
I authorize the nurses, doctors, trainers and emergency personnel to administer First Aid
or care as deemed necessary.
We, the undersigned, for ourselves, our heirs, executors and administrators, waive, release and
forever discharge The Paul Blodgett Goalkeeper Training School, L.L.C., it's staff, officers, agents,
representatives, employees, successors, and assigns to and form any and all rights
and claims for damages to person and property activities, or while partaking in
training at any site.
________________________________________________________________________________
| Date | Parent or Guardian's Signatur |