2007-2008 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 Medical Information:__________________________________________________________________________________

  Athlete Medical Release

Parent hereby authorizes USSA Northern Division, and/or their named coaches, to secure any hospital, medical, dental or surgical care, treatment and/or procedures for the above named athlete.  Parent also consents that in the event of injury to the athlete, coaches can sign for competitor 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.  The coaches shall notify Parent at the earliest possible time during or after such care, treatment and/or procedures.  Parent knowingly and voluntarily consents in advance to such care, treatment and or procedures to encourage the physicians and coaches to exercise their best judgment as to the requirements of such care, treatment and/or procedures.  Parent specifically indemnifies and holds harmless US Skiing, USSA/Western Region/Northern Division, and its coaches from any and all costs and/or claims arising out of such care, treatment and/or procedure.  

Hold Harmless and Indemnity Agreement

For the consideration of ski racing instruction and training performed by USSA, USSA/Western Region and/or USSA/Northern Division, we, the parents or legal guardians of ____________________________do hereby covenant and agree to hold harmless USSA, USSA/ Western Region, USSA/Northern Division, and any of their employees or volunteer workers, for any injuries sustained by our child or ward herein named above occurring out of natural activities of ski racing instruction, racing, or traveling to and from races or training camps.

Father’s or Guardian’s Signature: __________________________________________	Date: ________________________________
Mother's or Guardian’s Signature: __________________________________________	Date: ________________________________

USSA Insurance Policy

FIS and USSA rules require that competitors be covered by valid and sufficient accident insurance.  Proof of this insurance must be carried by the racer and be available at each race or camp so that prompt medical care can be obtained, if ever needed.  

Foreign Coverage [new, 09/05/2005] (if applicable) _______ Initials

We have verified with our insurance company that this policy is effective for care in foreign countries including Europe and South America.  Any additional information necessary is attached to this form.  Our son/daughter is traveling with a means of payment for medical services.  

Father's Signature and Date_____________________________________________________________________

Mother's Signature and Date_____________________________________________________________________

Agreement

We have read and understood the Insurance Policy statement.  The insurance policy listed on this form meets the requirements of the USSA Insurance Policy and will be maintained in force while the competitor is involved in a USSA, USSA/Western Region camp or team, USSA/Northern Division camp or team or while participating in any event on a US Skiing, USSA/Western Region quota or USSA/Northern Divisional quota.  We agree that we are responsible for any and all medical charges and we agree that we will promptly reimburse USSA, USSA/Western Region or USSA/Northern Division for any expenses that they or their coaches incur on behalf of the competitor.  

Athlete’s Signature: __________________________________________	Date: ________________________________
Parent's or Guardian’s Signature: __________________________________________	Date: ________________________________