Medical Release Form printable pdf download

South Carolina Youth Soccer

Medical Release Form

Fall 2014 Spring 2015

Function: All SC Youth Soccer events and league games, tournaments, friendlies

Player’s Name: __________________________________________________________________________

Address: _______________________________________________________________________________

City/State/Zip Code: ______________________________________________________________________

Birthdate: _______________________________________ Gender: ___________________________________

Home Phone: ____________________________________ Alternate Phone: _________________________

Email: __________________________________________ Alternate Email: __________________________

Parent/Guardian

Cell Phone

Home Phone

Work Phone

_________________________________

_______________

_________________________________

_______________

Contact Type

Name

Phone

Emergency Contact:

___________________________________

_______________

Physician:

___________________________________

_______________

Primary Medical Insurance Company: _________________________________________________________

Primary Number: __________________________________________________________________________

Known allergies or other pertinent medical information: ____________________________________________

I, the parent/guardian of the registrant, a minor, agree that the registrant and I abide by the rules of Carolina Elite Soccer Academy, SC Youth Soccer,

the US Youth Soccer, USSF and their affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in

consideration for Carolina Elite Soccer Academy, SC Youth Soccer, US Youth Soccer, USSF, Greenville County Recreation District, Greer Recreation

Department, MeSA, Certified Athletic Trainers from Bon Secours ST Francis Health, and Bon Secours ST Francis Health accepting the registrant for its

soccer programs and activities (the “Program”), I hereby release, discharge and/or otherwise indemnify Carolina Elite Soccer Academy, SC Youth

Soccer, US Youth Soccer, US Club Soccer, USSF, Greenville County Recreation District, Greer Recreation Department, MeSA, Certified Athletic

Trainers from Bon Secours ST Francis Health, and Bon Secours ST Francis Health their affiliated organizations and sponsors, their employees, medical

personnel, and associated personnel, including owners of fields, facilities utilized for Programs, against any claims by or on behalf of the registrant’s

participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

Therefore, I hereby grant my child’s coach or team manager permission to act as my agent in the area of obtaining medical treatment by a doctor of

medicine or dentistry. I also assume financial responsibility for any and all medical or dental treatment for my child. The above information pertaining to

my child is true and correct to the best of my knowledge. My child has received an examination by a physician and has been found physically capable of

participating in all of the CESA Soccer Programs.

____________________________________________

(Signature of Parent or Guardian)

Date:________________________________________