Butler County Soccer Association

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Medical Consent Form

Form

1. General Health:*

2. Problems:*

3. Regular Medications*

4. Allergies/Limitations*

5. Consent Agreement*

Please read and agree to the folloiwng:To induce the Butler County Soccer Association to accept registration and permit participation in BCSA by the individual, I/we, the parent(s) or guardian of said individual, hereby give my/our consent and agree to release BCSA, its officials, coaches, and representatives, from any claim arising out of injury to the named individual. I/We also hold harmless BCSA, its officials, coaches and representatives, from any claim arising out of injuries or conditions caused by or aggravated by my/our refusal to obtain medical treatment based on religious or philosophical belief.          I/We, the undersigned parent(s)/ guardian(s) of the participant, a minor, do hereby authorize the coaches, assistant coaches, or parents of the team members acting in the capacity of activity supervisors/vehicle drivers as agents for the undersigned to consent to medical, surgical, or dental examination and/or treatment. LEGAL AUTHORIZATION FOR EMERGENCY CARE AND ACKNOWLEDGEMENT OF DISCLAIMER.

I AGREE

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