Medical Release / Mandatory Health Form

Medical Release / Mandatory Health Form CONFIDENTIAL

AirBorne Volleyball Developmental Program

The information contained in this Mandatory Heath Form is confidential. The information will be disclosed only to the persons who are in need of the information. The form will be kept in a private place and will not be subject to public view.

______Name Phone

______Date of Birth

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Health History:

Any pre-existing or present medical conditions:

Check all that apply:

__ Hay Fever __ Heart Condition __ Asthma __ Diabetes __ Epilepsy/Nervous Disorders __ Frequent Stomach Upsets

__ Physical Disablity ______

__ Allergies ______Name and dosage of any medications that may be taken:

__ Medication Allergies ______

Emergency Contact Information:

______Name Relationship Phone

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By signing below I certify the above medical information to be true and accurate to the best of my knowledge. I also understand all reasonable safety precautions will be taken at all times by the Director, coaches and staff of AirBorne Volleyball during the practice times. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree to not hold AirBorne Volleyball, Conroe First Assembly or Lifestyle Christian School- their employees/ coaches /directors and staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

______Parent/Guardian Signature Date