MEDICAL RELEASE FORM
Authority to Treat and Waiver
PLAYER'S FULL NAME:____________________________________________________________________________________
ADDRESS:______________________________________________________________________________________________
CITY/STATE/ZIP:________________________________________________________________________________________
TELEPHONE #:_______________________ D.O.B._____ / _____ / _____
HEIGHT:_______ FT._______ IN.________ WEIGHT:_________________

The above named soccer player has been granted permission to attend and participate in and with teams, 

leagues, tournaments, camps, practices, and other soccer activities sponsored by the United States Youth 

Soccer Association.

The player has received a physical examination by a physician and is physically fit to participate.

In exchange for the privilege of the player participating in these activities. I waive any legal claim against 

those associated with these soccer activities in the event that the player is injured while participating in 

these soccer activities, and travel to and from the same.

I hereby give my consent, in case of injury, to have a coach, assistant coach, manager, athletic trainer, 

medical doctor, nurse, hospital, or clinic provide the player with medical assistance and or treatment. I agree 

to be financially responsible for the cost of such assistance or treatment.
KNOWN MEDICAL PROBLEMS:__________________________________________________________________________________
PHYSICIAN:___________________________________ TELEPHONE #:_______________________________________
INSURANCE:___________________________________ POLICY #:__________________________________________
In case of emergency, when parents cannot be reached, please contact:
NAME:________________________________________ TELEPHONE #:_______________________________________
_____________________________________________ ___________________________________________________
PRINT FATHER/GUARDIAN NAME: PRINT MOTHER/GUARDIAN NAME:
_____________________________________________ ___________________________________________________
SIGNATURE: SIGNATURE: