MEDICAL RELEASE FORM

As the parent/legal guardian of_______________________________, I request that in my absence
the above-named player be admitted to any hospital or medical facility for diagnosis and treatment.
I request and authorize physicians, dentists, and staff, duly licensed as Doctors of
Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any
diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the
above minor. I have not been given a guarantee as to the results of examination or treatment. I
authorize the hospital or medical facility to dispose of any specimen or tissue taken from the
above-named player.

Date of Player’s Birth: ____/____/____ Date of last Tetanus Booster ____/_____/_____
                                 Month Day Year                                             Month  Day   Year
Known allergies of this player, including any allergies to medicine _________________________
__________________________________________________________________________
Any other medical problems which should be noted ___________________________________
__________________________________________________________________________
Family Physician ____________________________________ Phone: ___________________
Name of Parent/Guardian ______________________________________________________
Address _________________________________________________________City/State/Zip
Phone _________________ H _____________________W ______________________FAX
Person responsible for charges (if different from above) ________________________________
Address__________________________________________________________ City/State/Zip
Phone __________________ H _____________________W _______________________FAX
Person to notify if parent/guardian is unavailable _______________________________________
Phone ___________________ H ____________________W _______________________FAX
Insurance Carrier __________________________ Policy Number _______________________

Signature of Parent/Guardian _____________________________________________________
                                                [NOTARIZATION]*
STATE OF_____________________________________________________ ))
))
COUNTY OF____________________________________________________ ))
Sworn to and subscribed before me on the ______ day of______ , 20____.
Notary Public in and for the State of _____________________________________
My Commission expires ___________________________________________

*Notarization is not required by US Youth Soccer.
NOTE: Please determine if this form is acceptable for planned use. Some Tournaments / Organizations
require customized forms.