2009-2010 Northern Division Medical Release
Name:_____________________________________Street Address:___________________________________ Birth Date:__________________________________City, State_______________________________________ E-Mail:_____________________________________Cell Number:_____________________________________ Father:_____________________________________Mother:_________________________________________ Home Phone:________________________________Home Phone:____________________________________ Work Phone:_________________________________Work Phone:_____________________________________ E-Mail:______________________________________E-Mail:__________________________________________ Cell Number:_________________________________Cell Number:_____________________________________
Insurance Coverage:
Company:___________________________________Identification #:__________________________________ Policy Number:________________________________Expiration Date:__________________________________
Medical History:
Allergies:_____________________________________________________________________________________ Medication:___________________________________________________________________________________ Other MedicalInformation:__________________________________________________________________________________
Athlete Medical Release
Parent hereby authorizes USSA Northern Division, and/or theirnamed coaches, to secure any hospital, medical, dental orsurgical care, treatment and/or procedures for the abovenamed athlete. Parent also consents that in the event ofinjury to the athlete, coaches can sign for competitor toreceive care, treatment and/or procedures, under theinstructions and directions of the licensed physicians on callat the emergency room of the nearest hospital or emergencyfacility. The coaches shall notify Parent at the earliestpossible time during or after such care, treatment and/orprocedures. Parent knowingly and voluntarily consents inadvance to such care, treatment and or procedures toencourage the physicians and coaches to exercise their best judgment as to the requirements of such care, treatmentand/or procedures. Parent specifically indemnifies and holdsharmless US Skiing, USSA/Western Region/NorthernDivision, and its coaches from any and all costs and/orclaims arising out of such care, treatment and/or procedure.
Hold Harmless and Indemnity Agreement
For the consideration of ski racing instruction and trainingperformed by USSA, USSA/Western Region and/orUSSA/Northern Division, we, the parents or legal guardians of ____________________________do hereby covenant andagree to hold harmless USSA, USSA/ Western Region,USSA/Northern Division, and any of their employees orvolunteer workers, for any injuries sustained by our child orward herein named above occurring out of natural activities ofski racing instruction, racing, or traveling to and from races or
10/14/2009 Medical Release for 2007northernussa.org/…/MedicalRelease.ht… 1/2
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