USA Volleyball Required Documents

Athlete Information

Athlete

First

Last

Date of Birth

Gender

Female
Male

Primary Contact: Parent or Guardian

Primary Contact

First

Last

Address Layout

Primary Email

Email

Confirm Email

Primary Phone

Primary Address

Address Line 1

Address Line 2

City

State

Zip Code

Secondary Contact

Contact Relationship

Is Parent / Guardian
Other

Secondary Contact Name

First

Last

Secondary Phone

Insurance Information

Primary Insurance Company

Enter the name of the primary insurance company.

Primary Group Number

Policy Number

Family Physician Name

Physician Phone

Medical Information

Medical Conditions

Please elaborate on any medical conditions of which we should be aware. If no conditions, enter NONE.

Medications

Please list any medications currently being taken. If no medications, enter NONE.

Concussion Last 24 Months?

Yes
No

In the past 24 months, have you been tested, diagnosed and/or treated for a concussion:

Allergies

Please list any allergies. If no known allergies, enter NONE.

The Participant listed above has my permission to participate in training, competition, events, activities and travel sponsored by USA Volleyball or any of its Regional Volleyball Associations (RVAs). I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed above. I understand and agree that this document will be kept in the possession of authorized adult team personnel and that reasonable care will be used to keep this information confidential. I agree to allow the authorized adult team personnel to release this information in the event of a medical emergency to a third-party medical provider. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above

Parent / Guardian Signature

Clear Signature

Signed Date / Time

Relationship to Player

Medical Response Option

OPTION 1: If, during the course of my daughter's/son's activities in volleyball, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.
OPTION 2: I do not authorize emergency medical/dental care for my daughter/son.

CHOOSE ONLY ONE OPTION ABOVE:

Concussion Management and Sudden Cardiac Arrest Acknowledgement

The Puget Sound Region of USA Volleyball believes participation in athletics improves physical fitness, coordination, self-discipline, and gives students valuable opportunities to learn important social and life skills.

With this in mind it is important we do as much as possible to create and maintain an enjoyable and safe environment. As a parent/guardian or student athlete you play a vital role in protecting participants and helping them get the best from sport.

Player and family education in this area is crucial which is the reason for the Concussion Management and Sudden Cardiac Arrest Awareness pamphlet you received. Refer to it regularly.

This acknowledgement must be signed annually by the parent/guardian and student athlete prior to participation in Puget Sound Region Volleyball events. If you have questions regarding any of the information provided in the pamphlet, please contact the athletic director at your school.

ZACHERY LYSEDT LAW COMPLIANCE STATEMENT

I certify:

I have been provided with information on concussions in youth sports in compliance with HB 1824.
I understand that on a yearly basis, the concussions in youth sports information sheet shall be signed and returned to the Puget Sound Region, USAV by myself (or my parent or legal guardian if I am under the age of eighteen (18) years old prior to my initiating practice or competition.
If any player/participant is suspected of suffering a concussion or brain injury, the player will be removed from practice or competition and not returned to practice or competition until cleared in writing by a licensed health care provider trained in the evaluation and management of concussions (Medical Doctors, Doctors of Osteopathy, Advanced Registered Nurse Practitioner, Physicians Assistants, and Certified Athletic Trainers).

I have received, read, and understand the information presented within the Sudden Cardiac Arrest Pamphlet.

Athlete Name

Athlete Signature

Clear Signature

Athlete Sign Date

Parent or Guardian Name

Parent or Guardian Signature

Clear Signature

Signature Date