LIGHTHOUSE
SOCCER CLUB - TRAVEL
FALL 2007-2008 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 |