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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: ___________________
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