HEALTH WAIVER | Empower Futbol

First Name

Email Address

Last Name

Primary Contact

If you answered yes to any question, please elaborate

Please list all your valid vaccinations. Please note that tetanus vaccination is strongly recommended (valid for 10 years).

I give my permission for the transmittal of the results of this medical examination to the different persons working with the team (physiotherapist, athletic therapist, doctor, coach and manager). However, this document is confidential and the details contained in it cannot be transmitted to another party without my consent (or my parent or guardian).

I give my permission and agree that the therapists/doctors working for Empower Athletics to give the proper emergency care and prevention and all the other treatments relevant to their professions to me (to my son/daughter). It is understood that as soon as possible, I will be informed of the problem, diagnosis, medical treatment required and the expected results.

Name (if over 18)

Name of parent/guardian

EMPOWER FUTBOL SCHOOL

Medical Questionnaire

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