Preview Medical Release Form

PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

Player’s Name: _____________________________________ Date of Birth: _________________________ Gender: ________________

Address: ________________________________________ City: ___________________________ State: _________ Zip: _______________

EMERGENCY INFORMATION

Father’s Name: ______________________________ Home Phone: ______________________ Work Phone: ____________________

Mother’s Name: _____________________________ Home Phone: ______________________ Work Phone: ____________________

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

Name: ________________________________________ Home Phone: ______________________ Work Phone: ___________________

Allergies: _________________________________________________________________________________________________________________

Other Medical Conditions: ______________________________________________________________________________________________

Player’s Physician: _______________________________ Home Phone: ____________________ Work Phone: __________________

Medical and/or Hospital Insurance Company: ______________________________________ Phone: ________________________

Policy Holder: _____________________________________ Policy #: ________________________ Group #: ________________________

PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS FORM

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.

____________________________________________________________________ _______________________________________________

Signature of Parent/Guardian Date

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