Tredyffrin-Easttown Youth Soccer Associaton Medical Release Form


Medical Release Form
Tredyffrin-Easttown Youth Soccer Associaton (TEYSA)
(Including all related activities - games, practices, travel, scrimmages, etc.)
Player's Name__________________________________________________________
Birth date:___________________ Sex:_____
Parent’s Names:________________________________________________________
Parent's Phone: Home(___ )___________________ Work( ___)__________________
Emergency contact (other than parent/guardian):
Name:_______________________________________ Phone (____ )______________
Primary medical insurance company_________________________________________
Policy number________________________________________________________________
Physician;_____________________________ Physician's Phone #(
Known allergies or other pertinent medical information:
Recognizing the possibility of physical injury associated with soccer and in consideration for the
TEYSA and affiliated organizations, including the Philadelphia Area Girls Soccer League
(PAGSL), the DELCO Soccer League (DELCO) and the USYSA and their affiliates- including
EPYSA, accepting the registrant for its soccer programs and activities (the "Programs"), I here-
by release, discharge, and/or otherwise indemnify TEYSA, including coaches, officers, directors
and/or others acting on its behalf), PAGSL, DELCO, USYSA, US Club Soccer, their 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 regis-
trant's participation in the Programs and/or being transported to or from the same, which
transportation I hereby authorize.
Therefore, I grant (coach)_____________________, (asst. coach)_______________________
and/or, in their absence, other responsible adults present acting on their behalf permission to
act as my surrogate for my child in the area of obtaining medical treatment by a doctor or medi-
cine or dentistry. I also assume financial responsibility for any medical treatment for my child.
Signature of Parent/Guardian:________________________________ Date:_______________
Parent's Name: (Print)__________________________________________


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