Medical Form And Release Form printable pdf download

MASSACHUSETTS YOUTH SOCCER ASSOCIATION, INC

Medical Form and Release

Players Name: ____________________________________________________ Date of Birth: _____________________

Address: __________________________________________________________________________________________

Email Address:__________________________________ Gender: ________ Age Group: ________

Teams on which you are currently rostered:

Club____________________________

___________________________

Parents’ Names: ____________________________________________________________________________________

Phone: _______________________ Cell Phone: ________________________ Email: ___________________________

If the parents cannot be reached, in an emergency please contact:

Name: ____________________________________________________ Telephone _____________________________

Player’s Allergies: ___________________________________________________________________________________

Other Medical Conditions: ____________________________________________________________________________

Player’s Physician: __________________________________________ Telephone: _____________________________

Medical Insurance Company: __________________________________ Telephone: ____________________________

Policy Holder: ___________________________________ Policy No: ____________________ Group No:____________

PARENTAL APPROVAL AND MEDICAL RELEASE

I hereby release and discharge the South Shore Select, Kick-it USA and South Shore Sports Center, and all coaches,

managers, officers and others participating in League and/or Club activities, from all liability for injuries to the above

name person and will defend and indemnify them from claims, lawsuits and other liabilities. I hereby give my approval to

his/her participation in all club sponsored events which will include but will not be limited to practice, tournaments and

league participation. Also, it is my understanding that insurance is not covered by this Soccer Club, or the Leagues and/or

Tournaments

they

may

enter.

I hereby give my permission for any medical attention necessary to be administered to my child, in the event of an

accident, injury, sickness, etc., during any South Shore Select Soccer, Kick-it USA and South Shore Sports Center event,

under the direction of a South Shore Select Soccer, Kick-it USA and South Shore Sports Center representative until I can be

contacted. I also hereby assume the responsibility for payment of any such necessary treatment.

______________________________________________________________ _________________________________

Signature of Parent

Date

Medical Form And Release Form