Medical Release Form Wmysa printable pdf download

West Michigan Youth Soccer Association

Medical Release Form

I,________________________________________hereby give my permission for any and all medical attention

necessary to be administered to my child (name)__________________________________ in the event of

accident, injury or illness, under the direction of the person(s) listed below, until such time as I may be

contacted. This release is effective for a period of one year from the date given below. I also assume the

responsibility for the payment of such treatment.

My address is:____________________________________________________________________________

Home Phone: (

)_________________________

Cell Phone: (

)__________________________

My insurance company is: __________________________________________________________________

My policy number is: ______________________________________________________________________

In case I cannot be reached, any of the following is designated to act I my behalf.

1. Head Coach

2. Assistant Coach/Manager

3. Team Parent

4. A league representative where my child is playing

5. Any tournament representative where my child is participating in an US Youth sanctioned tournament

Our physician is __________________________________________________________________________

Address: _________________________________________________________________________________

Telephone: __(

)________________________________________________________________________

Known Allergies: ___________________________________________________________________________

Medical Conditions: _________________________________________________________________________

Signature (Parent/Guardian):__________________________________________________________________

Subscribed and sworn to before me this ________ day of _________________________________, 20____

_____________________________________________________________

_____________________

Signature

Expiration date

Medical Release Form Wmysa