FLORIDA AAU VOLLEYBALL PROGRAM
MEDICAL HISTORY AND RELEASE FORM
This form must be carried with the coach during all training and competitions. Please complete all
sections of this form. Both the player and his or her parent/guardian must sign in all appropriate areas. By
signing this form, the participant and parent/guardian affirms they have read and understand it.
(CIRCLE ONE) M F
LAST NAME
FIRST NAME
MI
STREET ADDRESS
CITY
STATE ZIP CODE
/ /
BIRTH DATE
AGE
SOCIAL SECURITY NO. AAU MEMBERSHIPS NO.
TEAM NAME
DIVISION HEIGHT WEIGHT
The Participant, , has permission to participate in the AAU Junior
National Volleyball Program. I certify that the participant has full medical insurance with the company listed below
and is physically fit to engage in the activities of the program. I approve the leaders and coaches of this program
and recognize that they will serve to the best of their ability.
MUST SIGN: Date:
PARTICIPANT SIGNATURE
MUST SIGN: Relationship:
PARENT/GUARDIAN SIGNATURE
Print Name:
PARENT/GUARDIAN HOME PHONE WORK PHONE
STREET ADDRESS CITY STATE ZIP
DOES THIS POLICY COVER SPORTS RELATED ACCIDENTS?
INSURANCE COMPANY GROUP POLICY # (CIRCLE ONE) YES NO
MEDICAL RELEASE:
If my son or daughter should become ill or sustain an injury during his or her activities of the volleyball program, I
hereby authorize you to obtain emergency medical/dental care.
SIGN: Date:
PARENT/GUARDIAN SIGNATURE
I do not authorize emergency medical/dental care for my son or daughter.
SIGN: Date:
PARENT/GUARDIAN SIGNATURE
MEDICAL HISTORY
YES OR NO
DATE
PLEASE SPECIFY
ALLERGIES
Y
N
ASTHMA
Y
N
DIABETES
Y
N
EPILEPSY
Y
N
HEADACHES
Y
N
HEART
Y
N
KIDNEY DISEASE
Y
N
MOTION SICKNESS
INJURIES:
Y
N
ANKLE
Y
N
KNEE
Y
N
BACK
Y
N
HEAD/NECK
Y
N
SHOULDER
Y
N
ELBOW
Y
N
WRIST
Y
N
HAND
Y
N
FINGER
Y
N
OTHER
Y
N
IMMUNIZATIONS (please state month and year):
Tetanus Polio Measles (Rubella)
Is the participant taking any medications? NO YES
If yes, please name the drug(s), dosage and frequency needed:
Is there any psycho-social or physical condition for which the participant is currently under professional care?
NO YES
Please list any injuries the participant has suffered in the last two months:
Elaborate on any other medical conditions:
STATE OF
COUNTY OF
SWORN TO BEFORE ME, A NOTARY REPUBLIC, BY SAID PERSONALLY
KNOW TO ME THIS DAY OF ,20 .
NOTARY REPUBLIC
MY COMMISSION EXPIRES
