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ARSENAL ACADEMY MEDICAL RELEASE FORM

Authority to Treat and Waiver – Please Complete ALL Information

Dated: October 21, 2019

First Player's Name

First Name*

Middle Name

Last Name*

Phone*
First Player's Date of Birth*
First Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
First Player's Signature*
Second Player's Name

First Name*

Middle Name

Last Name*
Second Player's Date of Birth*
Second Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Third Player's Name

First Name*

Middle Name

Last Name*
Third Player's Date of Birth*
Third Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Fourth Player's Name

First Name*

Middle Name

Last Name*
Fourth Player's Date of Birth*
Fourth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Fifth Player's Name

First Name*

Middle Name

Last Name*
Fifth Player's Date of Birth*
Fifth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Sixth Player's Name

First Name*

Middle Name

Last Name*
Sixth Player's Date of Birth*
Sixth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Seventh Player's Name

First Name*

Middle Name

Last Name*
Seventh Player's Date of Birth*
Seventh Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Eighth Player's Name

First Name*

Middle Name

Last Name*
Eighth Player's Date of Birth*
Eighth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Ninth Player's Name

First Name*

Middle Name

Last Name*
Ninth Player's Date of Birth*
Ninth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Tenth Player's Name

First Name*

Middle Name

Last Name*
Tenth Player's Date of Birth*
Tenth Player's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Player's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

-In case of emergency, when parents cannot be reached, please contact:


Name: *

Telephone# *
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

School Grade: *

Shirt Size: *

Short Size: *
Sock Size*

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# *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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