Permission to Participate & Medical Authorization

FC NAPOLI

 

Athletes NAME: ________________________ Mailing Address: _______________________
Gender:  M / F City: ____________________________
Date of Birth:  ___ / ___ / ___ State: _______   Zip:________
   
Home Phone:_____________________ E-Mail Address: _______________________________

 

 

 

 

MEDICAL RELEASE:  

Medical Conditions

  1. List allergies, medications, illnesses, injuries, (etc) : __________________________________________________________________

 

    __________________________________________________________________

 

  1. In case of emergency notify: _________________________________

 

  1. Relationship to athlete:______________________________________

 

  1. Home Phone: ___________________   Other Phone: __________________

 

The above named athlete has my permission to participate in the FC Napoli club soccer program from July 1st through June 30th. I further certify that he/she is capable of participating in a strenuous physical activity, to wit soccer. I also agree to hold harmless the FC Napoli soccer club, its staff, agents, tournament sponsors, opponent teams or club, the Preparatory School of Marianpolis it's employees, and /or any associated organization from any and all injuries which may be sustained by the athlete during his/her participating in the program.

 

In case of emergency, I understand every attempt will be made to contact the person(s) listed above. If contact is unsuccessful, I give my permission to the tending physician to render medical treatment to the participant, including (if necessary) hospitalization. Any expense arising from or illness is the responsibility of the person signing below.

 

 

Insurance Company: _______________________   Policy Number: ______________

 

Parent Guardian Signature: ________________________________                  Date: ____________________