Fillable Usys/uss Medical Release Form printable pdf download

Usys/uss Medical Release Form

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Medical Release Form

Function: _______________________________________________________________________

Player’s Name:___________________________________________ U.S. Citizen Yes_______ No______

Address:______________________________________________________________________________

City/State/Zip Code: ____________________________________________________________________

Birthdate:________________________ Sex:____ Social Security Number:_________________________

Parent’s Phone: (_____)________________________Home (______)________________________ Work

Emergency phone number other than Parent/Guardian:

Name:_________________________________________ Phone: (_____)__________________________

Primary Medical Insurance

Company:_______________________________________________________

Policy Number: ________________________________________________________________________

Known allergies or other pertinent medical information: ________________________________________

_____________________________________________________________________________________

Recognizing the possibility of physical injury associated with soccer and in consideration for USYS/USS

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

release, discharge and/or otherwise indemnify USYS/USS, 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.

Therefore, 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 me this ______________ Day of ________________________________ 200_

Signature ________________________________ My commission expires _______________________

Notary Public

Usys/uss Medical Release Form

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