GPRC Wolves Volleyball Club Player Medical History Release Form

VOLLEYBALLCLUBGPRC Wolves Volleyball ClubPlayer Medical HistoryRelease FormThis form must be completed and signed in all areas by both players/parents or guardian. By signing this for the participant affirmshaving read it. This form must be carried with the coach for all training and competition.First Name____________________________________________Last Name____________________________________________Birth Date_____________________________________________Age_________________________________________________Sex_________________________________________________Parents(s) or GuardianEmergency ContactName(s) _____________________________________________Name _______________________________________________Address _____________________________________________Home Phone _________________________________________Home Phone _________________________________________Work Phone __________________________________________Work Phone __________________________________________Cell Phone ___________________________________________Cell Phone ___________________________________________AHC # ______________________________________________Email _______________________________________________Group/Policy # ________________________________________To Whom It May Concern:Does Policy Cover sport related accidents? Yes _____No______Participant, ______________________________________________________ ,has my permission to participate in training, competition,events, activities and travel sponsored by GPRC Wolves Volleyball Club. I approve of the leaders who will be in charge of theprogram. I recognise that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance withthe company listed above. I also certify to the best of my knowledge that the participant named heron is physically fit to engage in theactivities described above.Signed ______________________________________________ Date _______________________________________________Relationship __________________________________________To the Club Leaders:If during the course of my daughter’s/son’s activities in volleyball should she/he become ill or sustain an injury, I hearby authorise youto obtain emergency medical/dental care.Signed ______________________________________________ Date _______________________________________________

VOLLEYBALLCLUBImmunizations (Please state month and year)Tetanus ___________________________ Polio _________________________ Measles (Rubella) ___________________________Health HistoryYes No Date Please elaborate (especially on conditions that might be aggravated)Allergies _________ _______________________________________________________________Asthma _________ _______________________________________________________________Diabetes _________ _______________________________________________________________Epilepsy _________ _______________________________________________________________Heart _________ _______________________________________________________________Congenital Conditions: _________ _______________________________________________________________Previous InjuriesAnkles _________ _______________________________________________________________Knee _________ _______________________________________________________________Back _________ _______________________________________________________________Head/Neck _________ _______________________________________________________________Shoulder _________ _______________________________________________________________Elbow _________ _______________________________________________________________Wrist _________ _______________________________________________________________Hand _________ _______________________________________________________________Finger _________ _______________________________________________________________Other _________ _______________________________________________________________Height ______________________ Weight ______________________Is there any condition for which the participant is currently under professional care? Yes No If so please elaborate______________________________________________________________________________________________________________________________________________________________________________________________Is the participant currently taking any medication? Yes No If so please name the drug(s) dosage and frequency needed: ______________________________________________________________________________________________________________________________________________________________Please list any known drug allergies: ____________________________________________________________________________________________________________________________________________________________________________________Please elaborate on any medical conditions we should be aware of: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________