Arizona Youth Soccer Assosiation Medical Form
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1As the parent/legal guardian of __________________________ I request that in my absence the above-named player
to 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 minor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-
being of my dependant. 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 player’s birth: _____/_____/_____
Date of last tetanus booster: _____/_____/_____
MONTH
DAY
YEAR
MONTH
DAY
YEAR
Known allergies of this player, including any allergies to medication _______________________________________
______________________________________________________________________________________________
Are there any other medical problems that should be noted: _____________________________________________
Family Physician: _________________________________
Telephone: __________________________________
Name of parent/legal guardian: _____________________________________________________________________
Address: ______________________________ City: _____________________ State: _____________ Zip: ________
Telephone: (
) ______________________ (
) ______________________
(
) ____________________
HOME
WORK
CELL
Person responsible for charges (if different from above): _________________________________________________
Address: ______________________________ City: ______________________ State: ___________ Zip: ________
Telephone: (
) ________________________ (
) ______________________
(
) __________________
HOME
WORK
CELL
Person to notify if parent/guardian is unavailable: ______________________________________________________
Telephone: (
) ________________________ (
) ______________________
(
) __________________
HOME
WORK
CELL
Insurance Carrier: _______________________________ Policy number: __________________________________
I HEREBY AUTHORIZE THE OFFICE, LEADER, OR COACH, AGENT(S) OF THE ARIZONA STATE YOUTH
SOCCER ASSOCIATION TO TRANSPORT AS REQUIRED THE ABOVE MINOR TO AND FROM THE
ASSOCIATION SPONSORED ACTIVITIES INCLUDING, BUT NOT LIMITED TO ATHLETIC AND SOCIAL
EVENTS.
Parent/legal guardian signature: ________________________________________ Date: ___________________
STATE OF ________________}
} ss.
(Seal)
COUNTY OF ______________}
On this ____ day of _________, 20___, before me personally appeared ______________________ (name of signer)
whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to
this document, and who acknowledged that he/she signed the above document.
Notary Public _______________________________________
My Commission expires: _______________________________
****This document expires one year from the date of Notary, or the next playing season*****
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