Fillable North Carolina Medical Consent printable pdf download

NORTH CAROLINA Medical Consent / Waiver of Liability and Release

(To be given to your local association)

20 ____ - 20____

NCYSA

NCYSA Policy #

Excess policy to any valid and collectible

PO Box 18229

insurance. If there is no primary insurance on

Greensboro, NC 27419

insurance on a player, this policy is

336.856.7529

primary after the deductible.

Player First Name

M Initial

Last Name

Full Association Name

Jersey #

(AS APPEARS ON BIRTH CERTIFICATE)

[ ] Academy

[ ] Challenge

[ ] Classic

[ ] Recreation

[ ] Male

[ ] Female

Birth Date

Level

Sex

Address of Player

City

State

Zip

Parent/Legal Guardian Full Name

Home Phone

Work Phone

Cell Phone

Additional Person to Contact in an Emergency

Address

Home Phone

Cell Phone

Date of Last Tetanus Shot

Medications now being taken

Player is Allergic to these Medications and Substances

Parent Email For Soccer Information

List any Unusual Health Information

I (we), the undersigned, residing in the county of

, state of _________, the parents/legal guardian of the above Registrant,

a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team

affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association.

I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated

with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the “ Programs”), we hereby jointly and severally release,

discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and

facilities utilized by 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 we hereby authorize.

I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named

individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team

specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips

sponsored by or in conjunction with the Programs.

In addition, I (we) do hereby authorize any one of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain

consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment,

and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice.

The undersigned have read and fully understand and agree to the foregoing.

Insurance Information:

Name of Insurance Company:

**Parent/Legal Guardian Signature

ID Number:

**No Electronic Signature Permitted

Confirmation Number:

_____________________________________________

Date

Original (Team)

Copy (Association)