Vermont Soccer Association

Medical Release Form

Players Name:__________________________________U.S. Citizen Yes____No____

Address:_______________________________________________________________

Birthdate:_____________________Sex: ____________

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 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 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:_______________