Idaho Youth Soccer Association Medical Release

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IDAHO YOUTH SOCCER ASSOCIATION
MEDICAL RELEASE FORM
Coach’s copy - to be carried by coach to all games and practices.
Player’s Name_____________________________________________
Home Phone ________________________________
Address__________________________________________________
City/Zip____________________________________
Parent/Guardian Name______________________________________
Relationship________________________________
Parent/Guardian Address____________________________________
City/Zip____________________________________
Parent/Guardian Home Phone________________________________
Work Phone________________________________
Parent/Guardian Home Phone________________________________
Work Phone________________________________
Person To Notify In Case of Emergency __________________________________________________________________________
Home Phone______________________________________________
Work Phone________________________________
Doctor To Notify In Emergency______________________________
Phone_____________________________________
Hospital Preference, if any __________________________________
City_______________________________________
List Any Medical Problems Or Conditions Player Has (include allergies and medications currently taking)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
Family Insurance Information:
Child’s Birth Date___________________________
Insurance Company_______________________________________
Address_________________________________________________
City/State/Zip_______________________________
Subscriber Name__________________________________________
Do You Have A Dental Program________________
Subscriber Number________________________________________
Group Number______________________________
Subscriber Address________________________________________
City/Zip___________________________________
I hereby give my consent for all medical care prescribed by a duly licensed Doctor of Medicine for the above minor as his/her parent
or legal guardian. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my
dependent. To the best of the undersigned’s knowledge, all of the above information is true and accurate.
Signed__________________________________________________
Date______________________________________
Revised 6/21/07

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