Medical Release Form - Lake Washington Youth Soccer Association
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1LAKE WASHINGTON YOUTH SOCCER ASSOCIATION
12525 Willows Road NE, Suite 100, Kirkland, WA 98034
Phone: 425-821-1741
Fax: 425-820-0702
web site:
email:
MEDICAL RELEASE FORM
Parents:
Complete this form and return it to your player’s Coach or Team Manager.
Coaches/Managers: Keep forms with players at all LWYSA/WSYSA activities.
In the event of
injury requiring emergency medical attention, this form should accompany the player to the medical facility.
PERSONAL INFORMATION – PLEASE PRINT NEATLY
Last
First
___-___-___
Player
Birth Date
Male
Female
Last
First
Day
Evening
Mother
Phone
Last
First
Evening
Day
Father
Phone
Address
State
Zip
City
Last
First
Alternate
Relationship
Phone
Contact
Address
City
State
Zip
Last
First
Day
Emergency
Physician
Phone
Local Hospital or Medical Facility Preference
Insurance Carrier:
ID#
Person responsible for charges (if different from above):
MEDICAL HISTORY
Note: LWYSA may require a physician’s release for participation
Allergies
Prescription Meds
Drug Allergies
Last Tetanus Booster
____ - ____ - ____
Date
Does player have any condition that could potentially limit his/her physical ability or increase risk of injury as a result
of participating in athletic activities?
Yes___
No___
If Yes, please explain:
PARENT’S CONSENT
As the parent or legal guardian of the above registered participant, 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 minor. I have not been given any 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.
I certify that the information provided above is true and accurate to the best of my knowledge.
Signature:_______________________________________________ Date:_____________________________
Parent or Legal Guardian
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