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Parent/ Guardian Consent & Player Medical Release Form

PARENT/ GUARDIAN APPROVAL AND MEDICAL RELEASE

Recognizing the possibility of physical injury associated with soccer and in consideration for the VSA/USSF/US Youth Soccer and its affiliates accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the VSA/USSF/US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

My son/daughter 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 and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.

Today's Date: November 20, 2018

First Participant's Name

First Name*

Last Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
First Participant's Signature*
Second Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Third Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Fourth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Fifth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Sixth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Seventh Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Eighth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Ninth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Tenth Participant's Name

First Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
Participant'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

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
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*

Last Name*

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

In an emergency, when Parents or Guardians cannot be reached, please contact: 


Name:

Home Ph:

Cell Ph:

Medical History


Allergies:

Other Medical Conditions:

Player's Physician:

Office Phone:
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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