Medical Release Form
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1E
P
y
s
a
astErn
Ennsylvania
outh
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ssociation
Two Village Road, Suite 3, Horsham, PA 19044
Phone (215) 657-7727 • Fax (215) 657-7740 •
Medical Release
Player’s Name: ___________________________________________ Date of Birth: _______ / _______ / _______
Address: _________________________________________________________________________________________
City: _______________________________________________
State: __________ Zip: _________________
EMERGENCY INFORMATION (Please include Area Code)
Father’s Name: _________________________________
Mother’s Name: _________________________________
Father’s Home Phone: (
) ____________________
Mother’s Home Phone: (
) ____________________
Father’s WorkPhone: (
) _____________________
Mother’s WorkPhone: (
) ____________________
Father’s Cell Phone: (
) _____________________
Mother’s Cell Phone: (
) _____________________
Father’s E-mail: _________________________________ Mother’s E-mail: ________________________________
In an emergency, when parents cannot be reached, please contact:
Name: ___________________________________________
Home Phone: (
) _______________________ WorkPhone: (
) _______________________
Name: ___________________________________________
Home Phone: (
) _______________________ WorkPhone: (
) _______________________
Allergies: ________________________________________________________________________________________
Other Medical Conditions: _________________________________________________________________________
Player’s Physician: ____________________________________
Work Phone: (
) ________________________ 2nd Phone: (
) _______________________
__________________________ Phone: (
) __________________
Medical and/or Hospital Insurance Company:
Policy Holder: _______________________________ Policy #: _____________________ Group #: _______________
PLEASE COPY BOTH SIDES OF YOUR MEDICAL INSURANCE CARD
(copy both sides) onto 1 page (8.5 x 11) and attach to this form
PARENT’s APPROvAl ANd MEdICAl RElEAsE
Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/USYS/EPYSA
Youth Soccer and its affiliates accepting the registrant for its soccer programs and activities (“the Programs”), I hereby
release, discharge and/or otherwise indemnify the USSF/USYS/EPYSA, its affiliated organizations and sponsors, their
employees and associated personnel, including the owner of the 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 par-
ticipating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or den-
tistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for
the reasonable cost of each assistance and/or treatment.
____________________________________________________ ____________________________________
Signature of Parent/Guardian
Date
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