Fillable Player Information And Medical Release Form printable pdf download

United States Youth Soccer Association, Inc.

A division of United States Soccer Federation

KANSAS STATE YOUTH SOCCER ASSOCIATION

Player Information and Medical Release Form

Player’s Name______________________________________________________ Date of Birth ____________________

Address ______________________________________________City ________________ State _______ Zip ________

EMERGENCY INFORMATION

Father’s Name ___________________________________ Home Phone (____)_________Work Phone (____)_________

Mother’s Name __________________________________ Home Phone (____)_________Work Phone (____)_________

In an emergency when parents can’t be reached, please contact:

Name ________________________________________ Home Phone (____)__________Work Phone (____)__________

Allergies __________________________________________________________________________________________

Other Medical Conditions ____________________________________________________________________________

Player’s Physician ______________________________ Home Phone (____)__________Work Phone (____)__________

Medical and/or Hospital Insurance Company ___________________________________ Phone (____)_______________

Policy Holder _______________________________________ Policy Number __________________________________

PARENT’S APPROVAL AND MEDICAL RELEASE

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

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

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

associated personnel, including the owners of the fields and facilities utilized for 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 I hereby authorize.

My son/daughter has received a physical examination by a physician and has been found physically capable of

participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry

provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the

reasonable cost of such assistance and/or treatment.

__________________________________________________________

Signature of Parent/Guardian

Date

Subscribed and sworn to before me this ___________________ day of ____________________, ___________________

__________________________________________________________

Notary Public

(affix seal or original stamp)

My commission expires _______________________________________

Player Information And Medical Release Form