Medical Release

You may download this form in any of the following formats:

Administration – SAMPLE Soccer Medical Release Form

This form must be completed for each soccer player/participant under 18-years of age.

ORGANIZATION

MEDICAL RELEASE FORM

PLAYER’S NAME: _______________________________________________________________

ADDRESS: _______________________________________________________________

CITY: __________________________________ STATE: ___________

ZIP CODE: ______________

BIRTHDATE: ______________________________ GENDER: _________________

DATE OF MOST RECENT TETANUS SHOT: _______________________________

ANY KNOWN ALLERGIES (especially to medications): ________________________________

______________________________________________________________________________

MEDICAL CONDITIONS: ___________________________________________________

______________________________________________________________________________

PRIMARY MEDICAL INSURANCE COMPANY: _______________________________________

POLICY NUMBER: _________________________ GROUP OR TYPE NUMBER: ____________

PLAYER’S PRIMARY PHYSICIAN’S NAME: ____________________________________________

PHYSICIAN’S PHONE NUMBER: _____________________________________

PARENT OR LEGAL GUARDIAN NAME: _____________________________________________

HOME PHONE: ____________________________________________________

CELL PHONE: _____________________________________________

WORK PHONE: _____________________________________________

IN MY ABSENCE, ANY ONE OF THE FOLLOWING PEOPLE, IN THE ORDER IDENTIFIED BELOW, IS HEREBY DESIGNATED TO ACT ON MY BEHALF:

1. SECONDARY CONTACT NAME: _______________________________________

HOME PHONE: _______________________________

CELL PHONE: _________________________________________

WORK PHONE: _________________________________________

2. COACH: _________________________________________________________

3. ASSISTANT COACH/TEAM MANAGER: ______________________________________

4. TEAM PARENT: ___________________________________________________

5. A REPRESENTATIVE OF THE ORGANIZATION WHERE MY CHILD IS PLAYING

6. A REPRESENTATIVE OF THE TOURNAMENT WHERE MY CHILD IS PLAYING

In my absence, I hereby give my consent and permission for medical transportation and to have a paramedic and/or duly licensed Doctor of Medicine and/or duly licensed Doctor of Dentistry provide my child or legal guardian, a minor identified as “Player’s Name” above, with any and all medical assistance or treatment deemed necessary in the event of an accident, injury, or sudden illness. Further, I authorize admission to any hospital or medical facility for such treatment, including diagnostic procedures performed by licensed technicians or nurses. I authorize the hospital or medical facility to dispose of any specimens or tissue as appropriate. This release is effective until my arrival and it is revoked by me. I agree to be responsible financially for the cost of each transportation, assistance or treatment.

SIGNATURE: ___________________________________

DATE: ___________________________________

NOTARIZATION:

Subscribed and sworn (affirmed) to before me this ________ day of _____________, 20_______.

Signature _______________________________ My commission expires __________________

Notary Public

(Seal)

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Medical Release

Coaching American Soccer

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