PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

Player’s Name: _____________________________________ Date of Birth: _________________________ Gender: ________________

Address: ________________________________________ City: ___________________________ State: _________ Zip: _______________ EMERGENCY INFORMATION Parent/Guardian Name: _____________________________ Home Phone: ______________________ Work Phone: ____________________ Parent/Guardian Name: _____________________________ Home Phone: ______________________ Work Phone: ____________________ In an emergency, when parents cannot be reached, please contact: Name: ________________________________________ Home Phone: ______________________ Work Phone: ___________________ Name: ________________________________________ Home Phone: ______________________ Work Phone: ___________________ Allergies: _________________________________________________________________________________________________________________ Other Medical Conditions: ______________________________________________________________________________________________ Player’s Physician: _______________________________ Office Phone: ________________________ Medical and/or Hospital Insurance Company: ______________________________________ Phone: ________________________ Policy Holder: _____________________________________ Policy #: ________________________ Group #: ________________________ PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS FORM PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE Recognizing the possibility of injury or illness, and in consideration for Lions Legacy Athletic Academy and members of Lions Legacy Athletic Academy accepting my son/daughter as a player in the soccer programs and activities of Lions Legacy Athletic Academy and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify Lions Legacy Athletic Academy, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in fundamental sports training. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment. ____________________________________________________________________ _______________________________________________ Signature of Parent/Guardian Date