New Jersey Youth Soccer Medical Release Form printable pdf download

New Jersey Youth Soccer Medical Release Form

New Jersey Youth Soccer

Medical Release Form

Player’s Name

Date of Birth

Gender

Address

Town

State

Zip Code

Contact 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

Medical Information

Allergies

Other medical conditions

Player’s Physician

Phone

Primary Medical Insurance Company

Policy Holder

Policy #

Group #

PARENT’S APPROVAL AND MEDICAL RELEASE

Recognizing the possibility of physical injury associated with soccer and in consideration for New Jersey Youth Soccer accepting the

registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the New

Jersey 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 cost of each assistance and/or treatment.

Signature of Parent or Guardian

Date

6/28/2013

New Jersey Youth Soccer Medical Release Form