SAMPLE MEDICAL RELEASE FORM
© CoachingAmericanSoccer.com®
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, or other Club program 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)
© Copyright, John C. Harves