LIGHTHOUSE SOCCER
CLUB - TRAVEL
FALL 2010 MEDICAL RELEASE FORM Player’s Name: ________________________________ Address:
______________________________________________________________________ City:
Social Security Number:
__________________________________________ Parent’s Phone - Home: __________________________ Work: _________________________ Emergency phone number other than
Parent/Guardian Name:
__________________________________
Phone: _______________________________
Policy Number:
________________________________________________________________ Known allergies or other pertinent
medical information: ________________________________ ______________________________________________________________________________ ______________________________________________________________________________ Recognizing the possibility of
physical injury associated with soccer and in consideration for USYS/USS and
its affiliates accepting the registrant for its soccer programs and activities
(the “Programs”). I hereby release,
discharge and/or otherwise indemnify USYS/USS, its 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.
Signature
of Parent/Guardian:______________________________ Date: __________________
Notary Public |