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Cosmos Free Clinic 12/17
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Player's First Name
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Player's Last Name
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Your answer
Player's Date of Birth
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Gender
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Male
Female
Parent's Name
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Parent's Email
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Parent's Phone Number
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Your answer
I hereby give consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify CenCal Cosmos, their sponsors, its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the soccer player, which transportation I hereby authorize.
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