Medical Travel Form – G-Ball Academy

Player's Information

Player's Name *

Date Of Birth *

Gender *

Weight (lbs.) *

Height (ft. & in.) *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Parent Information

Parent 1 Name *

First

Last

Parent 1 Email *

Parent 1 Mobile Phone *

Parent 1 Home Phone

Parent 2 Name *

First

Last

Parent 2 Email *

Parent 2 Mobile Phone *

Parent 2 Home Phone

Emergency Contact

If Parents can not be reached, please provide an emergency contact.

Name *

First

Last

Phone *

Name

First

Last

Phone

Medical Information

Allergies *

Medical Conditions or Previous Surgeries *

Current Medications *

How many Covid Vaccinations (if any)? *

Layout

Physician *

Phone *

Medical Insurance Company *

Phone *

Policy Holder's Name *

Policy Number *

Agreement

MEDICAL TREATMENT AUTHORIZATION AND LAIBILITY WAIVER *

I Agree

By clicking Submit, I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with football (soccer), and hereby release, discharge, and otherwise indemnify G-Ball Academy Bermuda, and the employees and associated personnel of these organizations, against any claim by or on behalf of the player / participant named above as a result of that player’s participation in the G-Ball Academy UK Football Tour

Parent's Name *

Relation to Player *

Parent's Signature *

Clear Signature

Date *