MEDICAL FORM 2018

CB Soccer, LLC:  Kristi Beckman, Chris Beckman
Email:  kristi@cbsoccerllc.com
Health Form must be completed and scanned / emailed to above email address.

Important:  All information must be on file prior to training participation.

 Name____________________________ Age______ Date of Birth____________________

Address___________________________________________
City____________________________   State_____________ Zip_______________
Home Phone #______________________________
Mother’s Name___________________________ Mother’s work/mobile#_______________________
Father’s Name____________________________ Father’s work/mobile#________________________

EMERGENCY INFORMATION

Name of contact person (other than parents) ___________________________
Telephone #__________________________ Relationship to camper______________________

List ANY Allergies (Medication, Food, Environmental)
__________________________________________________________________________________________________________________________________________________________________________________________
 
List ANY Medications being taken (include DOSAGE and PURPOSE for MEDICATION)
__________________________________________________________________________________________________________________________________________________________________________________________
 
List ANY Orthopedic or Head injuries WITHIN THE PAST YEAR & Describe Nature/Severity of the Injury (include date of injury)
__________________________________________________________________________________________________________________________________________________________________________________________
 
Family Physician__________________________ Phone#________________________
Address_______________________________________________________________________
Date of Last Physical Exam_______________________
Date of Last Tetanus Booster_______________________
Health Insurance Company_________________________
Health Insurance Address_________________________________________________________
Health Insurance Group & Policy #s_________________________________________________
Name of Person who is Primary Holder______________________________________________

I understand that I am financially responsible for any medical bills incurred by my child while at CB Soccer, LLC training. In case of emergency, I grant permission for my child to be given emergency treatment by the appropriate medical personnel. In consideration of participation of my child in the training activities at CB Soccer, LLC, on behalf of myself, my heirs, executors, administrators, successors, or assigns, I hereby release and forever discharge CB Soccer LLC, its agents, servants, and employees of and from any and all manner of actions, causes of actions, suits, damages, claims and demands, on account of personal injury, including death, or any cause whatsoever, which I may have against them by reason of or arising out of participation in CB Soccer, LLC activities.
 

Signature of Parent/Guardian_________________________________________  Date_____________

Link to download form:  Medical Release Form