US Youth Soccer Medical Release

Affiliate Name *

Player First Name *

Player Middle Initial *

Player Last Name *

Date of Birth *

Street Address *

City *

State *

Zip Code *

Phone Number *

Gender

Team Information

Signature of Parent *

Clear

Date *

US Youth Soccer

PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

Father's Printed Name *

Father's Phone Number (Home/Cell) *

Mother's Printed Name *

Mother's Phone Number (Home/Cell) *

In an emergency, when parents cannot be reached, please contact:

Emergency Contact (1) Name: *

Emergency Contact (1) Home Phone: *

Emergency Contact (1) Work Phone: *

Emergency Contact (2) Name: *

Emergency Contact (2) Home Phone: *

Emergency Contact (2) Work Phone: *

Allergies *

Other Medical Conditions: *

Player's Physician: *

Physician Phone: *

Medical and/or Hospital Insurance Company: *

Insurance Phone Number: *

Policy Holder: *

Policy # *

Group #: *

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter's participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

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