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 authorized 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, operated procedures and x-ray treatment of the above minor.  I have not been given a guaranteed as to the results of the examination or treatment.  I authorized a hospital or medical facility to dispose of any specimen or tissue taken from the above named player.

Date of players birth (MM/DD/YY) ____/____/____    
Date at last tetanus booster (MM/DD/YY)___/___/___

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 ______________________________________________________________________

Phone at Home__________________________________   Phone at Work ____________________

Person responsible for charges (if different from above) ______________________________________

Address _________________________________________________________________________

Phone at Home__________________________________   Phone at Work _____________________

Insurance Carrier_________________________________  Policy number _____________________

Signature of Parent/Guardian _____________________________________________

STATE OF _______________   COUNTY OF ________________

Sworn to and subscribed before me on the ______day of _____________________, 20______.

Notary Public in and for the State the of ________________________________

My Commission expires ____________________________

*notarization is not required by US Youth Soccer.