2012-2013 Northern Division Medical Release

Athlete Name:________________________________	Address:__________________________________
City, State, Zip________________________________	Birth Date:_________________________________
E-Mail:______________________________________	Cell Phone::________________________________
Parent:______________________________________	Parent:___________________________________
Cell Phone:__________________________________	Cell Phone:________________________________
Home Phone:________________________________	Home Phone:______________________________
Work Phone:_________________________________	Work Phone:_______________________________
Email:_______________________________________	Email:____________________________________
Insurance Coverage:
Company:___________________________________	ID #:______________________________________
Policy #:_____________________________________	Expiration Date:_____________________________
Medical History:
Allergies:_________________________________________________________________________________
Medication:_______________________________________________________________________________
Other Medical Information:_______________________________________________________________________________

Foreign Coverage (for athletes traveling outside the U.S. including Canada):  We have verified with our insurance company that this policy is effective for care in foreign countries.  Any additional information necessary is attached to this form.  Our son/daughter will travel with a means of payment for medical services (e.g. credit card)

Athlete Medical Release Athlete or Parent, if athlete is under the age of 18 years, hereby authorizes USSA/Northern Division/Western Region Staff to secure hospital, medical, surgical and dental care or treatment and/or procedures for the above named athlete.  Parent also consents that in the event of injury to the athlete, coaches can authorize that athlete to receive care, treatment and /or procedures, under the instructions and directions of the licensed physicians on call at the emergency room of the nearest hospital or emergency facility.  USSA/Northern Division/Western Region shall notify Parent at the earliest possible time before, during, or after such care, treatment and/or procedures are authorized.  Parent knowingly and voluntarily consents in advance to such care, treatment and or procedures to encourage physicians and USSA/Northern Division/Western Region to exercise their best judgment as to the requirements of such care, treatment and/or procedures.  Parent specifically holds harmless and indemnifies USSA/Northern Division/Western Region of and from any and/or claims of any nature arising out of the provision of such care, treatment and/or procedure.

Please send to:  USSA Northern Division, P.O. Box 217, Whitefish, MT  59937, or FAX to 406-545-2289