Medical Release Form - Soccer

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Vermont Soccer Association
Medical Release Form
Players Name
U.S. Citizen Yes______No
:____________________________________
____
Address
:________________________________________________________________
Birthdate
Sex
M
:____________________
: _
____
___
F
Parent’s Phone Home
Work
:_______________________
: ________________________
Email Address
: ___________________________________________________________
Emergency phone number other than Parent/Guardian
:___________________________________
: _________________________
Name
Phone
: ____________________________________________
Primary Medical Insurance Company
: ___________________________________________________________
Policy Number
:
Known allergies or other pertinent medical information
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
________________________________________________________________________
Recognizing the possibility of physical injury associated with soccer and in consideration for
VSA/USYS/USSF and it’s affiliates accepting the registrant for its soccer programs and activities
(the “Programs”) I hereby release, discharge and/or otherwise indemnify VSA/USYS/USSF, it’s
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
registrant’s participation in the Programs, and/or being transported to or from the same, which
transportation I hereby authorize. My child has received a physical examination by a physician
and has been found physically capable of participating in the Programs.
Therefore, I grant___________________________and/or_________________________
permission to act as my surrogate for my child in the area of obtaining medical treatment by a
doctor of medicine or dentistry. I also assume the financial responsibility for any medical
treatment for my child.
Signature of Parent/Guardian:____________________________Date:_______________

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