Vermont Soccer Association

 

Medical Release Form

 

 

 

Players Name:__________________________________U.S. CitizenYes____No____

 

Address:_______________________________________________________________

 

Birthdate:_____________________Sex:†† ____________

 

Parentís 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 itís affiliates accepting the registrant for its soccer programs and activities (the ďProgramsĒ) I hereby release, discharge and/or otherwise indemnify USYS/USSF, itís 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 registrantís 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:_______________