Player Medical Release Form

Player Medical Release Form
Player's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
SSN:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
EMERGENCY INFORMATION
Father's Name:

First NameLast Name
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Mother's Name:

First NameLast Name
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
In an emergency, when parents cannot be reached, please contact:
Name:

First NameLast Name
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Name:

First NameLast Name
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Allergies:
Other Medical Conditions:
Player's Physician:

First NameLast Name
Home Phone:
Format: (000) 000-0000.
Work Phone:
Format: (000) 000-0000.
Medical and/or Hospital Insurance Company:
Phone:
Format: (000) 000-0000.
Policy Holder:
Policy #:
Group #:
PARENT'S APPROVAL AND MEDICAL RELEASE
Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/US Youth Soccer and its affiliates accepting the registrant for its soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the USSF/US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.
My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.
Signature of Parent/Guardian
Date

MonthDayYear
Date
Should be Empty:

Player Medical Release Form

EMERGENCY INFORMATION

PARENT'S APPROVAL AND MEDICAL RELEASE