Medical Release Form printable pdf download

Medical Release Form

Last Updated: 01/12/2013

Player:

Father/Guardian:

Address:

Work/Cell Phone:

Home Phone:

Mother/Guardian:

Date of Birth:

Work/Cell Phone:

Gender:

Height:

Secondary Contact:

Weight:

Phone:

Doctor:

Dentist:

Doctor Phone:

Dentist Phone:

Preferred

Insurance Carrier:

Hospital:

Policy Number:

Asthma:

Heart Trouble:

Diabetes:

Hearing Disability:

Convulsions:

Wears Contacts:

Learning Disability:

Wears Braces:

Drug Allergies:

Medications (Specify):

Kidney Disease:

Other (Explain Below)

Explanations:

Consent For Medical Treatment

As the parent or legal guardian of the above-named player, I request that in my absence my child 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 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 a guarantee as to the results of examination or treatment.

Release of Liability

Recognizing the possibility of injury associated with soccer and in consideration for the USSF/USYSA and its affiliates accepting the above-

named player for its soccer program and activities, I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, its affiliated

organizations and sponsors, their employees and personnel, including the owners of the fields and facilities utilized for the League/Tournament

contents against any claim by or on behalf of the player as a result of the player's participation.

Signature of Parent/Guardian

Date

Medical Release Form

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