Medical Release Form printable pdf download

Administration – Sample Medical Release Form

This form must be completed for each soccer player/participant under 18-years of age.

ORGANIZATION

MEDICAL RELEASE FORM

PLAYER’S NAME:

_______________________________________________________________

ADDRESS:

_______________________________________________________________

CITY: _________________________________

STATE: __________

ZIP CODE:

_____________

BIRTHDATE:

_________________________________

GENDER:

_________________

DATE OF MOST RECENT TETANUS SHOT:

_____________________________

ANY KNOWN ALLERGIES (especially to medications):

____________________________________

__________________________________________________________________________________

MEDICAL CONDITIONS:

________________________________________________________

__________________________________________________________________________________

PRIMARY MEDICAL INSURANCE COMPANY:

___________________________________________

POLICY NUMBER:

____________________

GROUP OR TYPE NUMBER:

__________

PLAYER’S PRIMARY PHYSICIAN’S NAME:

___________________________________________

PHYSICIAN’S PHONE NUMBER:

___________________________________________

PARENT OR LEGAL GUARDIAN NAME:

__________________________________________________

HOME PHONE:

___________________________________________________

CELL PHONE:

___________________________________________________

WORK PHONE:

___________________________________________________

IN MY ABSENCE, ANY ONE OF THE FOLLOWING PEOPLE, IN THE ORDER IDENTIFIED BELOW, IS HEREBY

DESIGNATED TO ACT ON MY BEHALF:

SECONDARY CONTACT NAME:

_______________________________________

HOME PHONE:

_______________________________

Medical Release Form

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