Fillable Medical Release Form - Youth Soccer printable pdf download

South Carolina Youth Soccer

Medical Release Form

Function: ______________________________________________________________________________

Player’s Name: __________________________________________________________________________

Address: _______________________________________________________________________________

City/State/Zip Code: ______________________________________________________________________

Birthdate: _______________________________________ Sex: ___________________________________

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: ____________________________________________

Recognizing the possibility of physical injury associated with soccer and in consideration for US Youth Soccer/USSF/SC Youth

Soccer and its affiliates accepting the registrant for its soccer program and activities (the “Programs”), I hereby release, discharge

and/or otherwise indemnify US Youth Soccer/USSF/Sc Youth Soccer, its affiliated organizations and sponsors, their employees and

associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim 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. My

child has received a physical examination by a physician and has been found physically capable of participating in the Programs.

Thereby, I grant __________ and/or __________ permission to act as my surrogate for my child in the area of obtaining medical

treatment by a doctor of medicine or dentistry. I also assume the financial responsibility for any medical treatment for my child.

Signature of Parent/Guardian: ___________________________________

Date: _____________________

Subscribed and sworn to before me this __________ day of _______________, 20 _____

Notary Public ______________________________________________

My commission expires _________________________

(Notarization not Required)

Medical Release Form - Youth Soccer