Waiver Of Liability Form - Authorization For Medical And/or Dental Treatment Form

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WAIVER OF LIABILITY FORM
AUTHORIZATION FOR MEDICAL AND/OR DENTAL TREATMENT FORM
As the parent/legal guardian of ____________________________________________, I request that in my absence the
above named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize
physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed
technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray
treatment of the above named minor. I have not been given a guarantee as to the results of examination or treatment. I
authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.
Date of Players Birth
/
__ / __
Date of last Tetanus Booster
/
/ __
.
Month
Day
Year
Month
Day
Year
Known allergies of this player, including any allergies to medicine___________________________________________
Any other medical problems which should be noted _____________________________________________________
Family Physician ___________________________________________ Phone ________________________________
Name of Parent/Guardian __________________________________________________________________________
Address ________________________________________________________________________________________
City/State/Zip ____________________________________________________________________________________
Phone (Home) ___________________ (Work) ______________________ (FAX)______________________________
Person responsible for charges (if different from above) ___________________________________________________
Address _________________________________________________________________________________________
City/State/Zip ____________________________________________________________________________________
Phone (Home) ___________________ (Work) ______________________ (FAX)______________________________
Person to notify if parent/guardian is unavailable ________________________________________________________
Phone (Home) _____________________ (Work) _______________________ (FAX)___________________________
Insurance Carrier________________________________________ Policy Number _____________________________
WAIVER OF LIABILITY
I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of United States
Youth Soccer, (a.k.a. USYS), its affiliated organizations and sponsors. Recognizing the possibility of physical injury
associated with soccer and in consideration for USYS accepting the registrant for its soccer programs and activities (the
“Programs”), I hereby release, discharge and/or otherwise indemnify USYS, its affiliated organizations, and sponsors,
their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs,
against any and/or all claims 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.
KYSA 2/04 ease check our website for further updated information: or .ORG
Signature of Parent / Guardian _________________________________________________ Date _________________
NOTARY PUBLIC
STATE OF ____________________________, COUNTY OF ________________________
Sworn to and subscribed before me on the ___________ day of ___________, 20__________
Notary Public in and for the State of ______________________________________________
My Commission expires: ________________________________________________________
(Place notary seal above.)

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