Tredyffrin-Easttown Youth Soccer Associaton Medical Release Form printable pdf download

Medical Release Form

Tredyffrin-Easttown Youth Soccer Associaton (TEYSA)

CLUB (TRAVEL) SOCCER

(Including all related activities - games, practices, travel, scrimmages, etc.)

Player's Name__________________________________________________________

Address:_______________________________________________________________

City/State/Zip___________________________________________________________

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)__________________________________________

Tredyffrin-Easttown Youth Soccer Associaton Medical Release Form