Vermont Voltage Overnight Camp – Lyndon State College
June 22, 2008– June 27, 2008 (Week 1)
July 6, 2008– July 11, 2008 (Week 2)
July 20, 2008– July 25, 2008 (Week 3)
LIABILITY/MEDICAL RELEASE FORM
One form must be completed for each child that will be traveling to a Voltage Game
with the Vermont Voltage Soccer Team!
Child’s Name _____________________________________ Birth Date________________
Address _________________________________________ Grade in School____________
City_________________________ State______ Zip_______ Phone # ( )_____________
I, _________________________________(name) give permission to my above-named son/daughter to travel to St. Albans or Essex with the Vermont Voltage soccer team on June 25, 2008 (1st camp), July 9, 2008 (2nd camp), or July 23, 2008 (3rd camp) to attend a Voltage game. If needed for health reasons, I give permission for my child to be evaluated, diagnosed, treated, and /or given medication in accordance with standard medical practice by licensed medical personnel. I relieve Bo Vuckovic and International Soccer Academy, Inc. (dba Vermont Voltage) of all responsibility and consequences that may arise as a result of this treatment. I will not hold Bo Vuckovic or International Soccer Academy, Inc. (dba Vermont Voltage) liable in the event of injury. Further, I agree to accept any and all financial responsibility as a result of scheduling medical staff. My child agrees to abide by all the rules and regulations stated by Bo Vuckovic and International Soccer Academy, Inc. (dba Vermont Voltage) and the Voltage staff. I understand that Bo Vuckovic and International Soccer Academy, Inc (dba Vermont Voltage) will not be held liable if my child fails to cooperate with regulations.
Family Physician __________________________________ Phone # ( )____________________
Allergies:
Environmental (i.e. pollen, dust…)__________________________________________________
Medications____________________________________________________________________
Food_________________________________________________________________________
Current Medications_____________________________________________________________
Medical History (be specific)______________________________________________________
Mental Health Information (be specific)______________________________________________
Medical Insurance Provider _________________________ Insurance No.__________________
In case of emergency, please contact:
Name______________________________ Name_______________________________
Address____________________________ Address_____________________________
_____________________________ ______________________________
Phone #: Home ( )___________________ Phone #: Home ( )___________________
Work ( )___________________ Work ( )____________________