Emergency Medical Release & Liability Waiver

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Emergency Medical Release & Liability Waiver
Participant’s Name____________________________________________________ Birthdate________________________
Street Address ____________________________________City _________________________________ Zip___________
EMERGENCY INFORMATION
Father's Name______________________________
(_____)____________
(_____)____________
Home Phone
Cell/Bus Phone
Mother's Name _____________________________
(_____)____________
(_____)____________
Home Phone
Cell/Bus Phone
In an emergency when parent/guardian cannot be reached or is not applicable, please contact the following:
Name_____________________________________
(_____)____________
(_____)____________
Home Phone
Cell/Bus Phone
Name________________________________
(_____)____________
(_____)____________
Home Phone
Cell/Bus Phone
Allergies____________________________________________________________________________________________
Other Medical Conditions_______________________________________________________________________________
Physician___________________________________ Cell Phone (_____)____________ Bus Phone (_____)____________
Medical/Hospital Insurance Company_________________________________________ Phone (_____)________________
Policy Holder's Name_______________________________________ Policy Number_______________________________
THIS AUTHORIZATION FOR EMERGENCY MEDICALTREATMENT MUST BE COMPLETED BEFORE PARTICIPANT
(PLAYER/COACH/REFEREE) CAN PARTICIPATE IN ACTIVITIES.
TREATMENT FOR INJURY WILL BE BASED ON
INFORMATION PROVIDED HEREIN.
I the undersigned participant and parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand
that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and
economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of
play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at
this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death,
hereby release, discharge, covenants to indemnify and not to sue Illinois Youth Soccer Association, its directors, officers, employees, coaches,
managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to
conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of
kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Programs and/or being
transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The
applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Programs. I
hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the
applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or
treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss,
cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or
lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above
waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this
document may not be altered in any manner and that any alternation without the express written consent from the Illinois Youth Soccer Association
will cause the participant to be removed from the Program. (revised 7/14/06)
Parents/Guardians Signature__________________________________________________ Date_____________________
(Parents/Guardians’ Signature is required if participant is under the age of 18)
Participant’s Signature_______________________________________________________ Date_____________________
(Participant’s Signature is required)
NOTE: ATTACH COPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO EXPEDITE MEDICAL TREATMENT.

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