LIGHTHOUSE SOCCER CLUB - TRAVEL

FALL 2007-2008 MEDICAL RELEASE FORM

 

 

 

 

Player’s Name:  ________________________________  US Citizen:  Yes     or     No

 

Address: ______________________________________________________________________

 

City: ___________________________________  State: _________  Zip: __________________


Birthdate: ______________________________  Sex:  M     or     F

 

Social Security Number: __________________________________________

 

Parent’s Phone - Home: __________________________  Work: _________________________

 

Emergency phone number other than Parent/Guardian

 

Name: __________________________________  Phone: _______________________________


Primary Medical Insurance Company: ______________________________________________

 

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.


Therefore, I grant ________________________ and/or ___________________ permission to act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or dentistry. 
I also assume the financial responsibility for any medical treatment for my child.

 

Signature of Parent/Guardian:______________________________  Date: __________________


Subscribed and sworn to me this ____________ Day of ______________________, 20_______


Signature: __________________________________  My commission expires: ______________

                 Notary Public