Medical Release Form

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Union of Students Football@footylikeclub


Player’s Name___________________

D.O.B.: __DD/__MM/__YY Gender: M / F
Address: ____________________ City: _________________________________ Postal Address:___________
Emergency Information
Father’s Name: Home Phone:
Mother’s Name: Home Phone:
In an emergency, when parents cannot be reached, please contact:
BFF Name (1): Home Phone:
BFF Name (2): Home Phone:
Other Medical Conditions:
Player’s Physician: Home Phone:
Medical and/or Hospital Insurance Company:
Company Name:__________________________________ Work Phone:_______________
Policy Holder:________ Policy Number:________
Recognizing the possibility of fever, injury or illness, and in consideration for Union of Students Football accepting my son/daughter as a player in the iFM Game programs and activities of Union of Students Football and its members (the “Program”), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify connect, its associated partners, their employees, and organizer including connect platform and sources utilized for the Program, against any claim by or on behalf of my player son/daughter as a result of my son’s/daughter’s participation in the Programs and/or being transfer credits to the Program window. I hereby authorise the transactions of my son/daughter to the Program.
My player son/daughter has received an eye test checked by our IT professional and has been found mentally capable of participating in the sport of football. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child and his friends have or that may impact their participation in the Programs. I give my consent to have a remittance officer and AI chatbot provide my son/daughter with limited assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.
_____________________________ _____________________________
Signature of Parent/Guardian Date

*If you have any questions about our issues raised within it, please contact us.

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