Dan Bulley Soccer School
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Medical Treatment Authorization Form 

Participants Name
D.O.B __________


1. List any medical conditions that camp personnel should be aware of

2. List any medications currently taking _______________________________

3. List any allergies ________________________________________________

In case of an emergency please contact:

Name _____________________________________________

Cell phone _______________________________________

Daytime phone ____________________________________

Medical insurance company ________________________

Insurance policy number __________________________
______________________________________, as parent or legal guardian of the participant named above, authorizes DBSS to seek medical and/or surgical treatment which is reasonably necessary to take care of the participant. I further authorize the medical facility that treats the participant to release all the information needed to complete the insurance claims. I acknowledge my responsibility to pay all costs associated with the participant’s medical care and authorize all insurance payments, if any, to be made directly to the medical facility.

__________________________________________________

Signature (Parent or Guardian)

Date
​


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  • Home
  • DBSS STING
    • Coaching Staff 2020/21
  • Programs
    • Performing Arts
    • Summer 2021 >
      • DBSS SUNSHINE TOURNAMENT
      • DBSS Summer Camp Series
      • DBSS HOMESCHOOL
    • DBSS LEADS
    • Winter Training 2019/20 >
      • Winter Player Development Programs
    • DBSS IN THE COMMUNITY
    • Individual and Group Sessions
    • DBSS High School Academy
  • Registration
    • WAIVERS AND FORMS
  • Coaches
    • Dan Bulley >
      • Dan Bulley Master's Degree
      • Dan Bulley Philosophy
      • Dan Bulley Master's Degree-Video
    • Adam Wright
    • Tom Bulley
  • About
    • Mission Statement
    • Philosophy
    • DBSS MEDIA COVERAGE
    • Videos and Education >
      • Coach and Parent Education
      • Player Expectations
      • Parent Expectations
      • Levels of Engagement
  • Contact
  • What's New