Medical Release Form General Release - Natick Soccer printable pdf download

Natick Soccer Club

Columbus Day Tournament

MEDICAL RELEASE FORM

As the parent/legal guardian of ___________________________, I request that in my absence

the above-named player be admitted to any hospital or medical facility for diagnosis and

treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of

Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any

diagnostic procedures, treatment procedures, operative procedures and x-ray treatment. I

authorize the hospital or medical facility to dispose of any specimen or tissue taken from the

above-named player.

Date of Player’s Birth: _____/_____/______

Month Day

Year

Known allergies of this player, including any allergies to medicine _______________________________

Any other medical problems which should be noted ___________________________________________

Family Physician __________________________________________ Phone ______________________

Name of Parent/Guardian ______________________________________________________________

Address:______________________________________City/State/Zip:____________________________

Phone(H)_______________________(W)_______________________(Email)______________________

Person to notify if parent/guardian is unavailable

Address:______________________________________City/State/Zip:____________________________

Phone(H)_______________________(W)_______________________(Email)______________________

Insurance Carrier: _____________________________________

Signature of Parent/Guardian _____________________________________________________

GENERAL RELEASE

I hereby acknowledge that participation in soccer competition carries with it potential hazard. I therefore release the

Natick Soccer Club and it’s team coaches, the officers and officials of the Tournament, and the Town of Natick, of

liability in the event of injury during the Natick Soccer Club’s Columbus Day Tournament.

Participant’s signature _________________________________________________________________

Participant’s Birthdate _________________________________________________________________

Parent/Guardian’s signature _____________________________________________________________

Team Name / Age Group / Division _______________________________________________________

Soccer Club Affiliation _________________________________________________________________

Date _________________________________

Note: Coaches should reproduce this form and have each player compete this medical release form. Bring the

original forms and a copy to registration on Friday for verification. The original forms MUST be carried by

the coach at ALL tournament games. Copies will be kept by the tournament committee.

Medical Release Form General Release - Natick Soccer