Medical Release Form
Print this form and return by 7/6 for the 2011 Fall soccer season [print version]:
PLEASE PRINT CLEARLY
Player info:
Player’s name: ______________________________
Date of birth: ___/___/____
Address (include zip code): ___________________________________________
School and grade in Sept. ’11: ___________________________
Uniform size (please circle one): YS YM YL AS AM AL AXL
(or if wearing last year’s uniform, jersey # ___ )
Shoe size (for socks): ___
Parent/guardian info:
Name/relationship: ______________________________
home #: ________________
work #: ___________________ cell#: ___________________
email address: ______________________________________
Name/relationship: ______________________________
home #: ________________
work #: ___________________ cell #: __________________
email address: ______________________________________
Emergency info:
allergies: ________________________________________________________
other medical conditions: ____________________________________________
medications: _____________________________________________________
player’s physician: ___________________________
phone #: ___________________
medical insurance company: _________________________________________
policy holder: _______________________________
policy #: ___________________
emergency contact (other than parent/guardian):
name and relationship: _____________________________________________
home #: ___________________ cell #: ___________________
Approval and medical release:
Recognizing the possibility of physical injury associated with soccer and in consideration for the Palumbo Soccer Club accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge, and/or otherwise indemnify the Palumbo Soccer Club, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.
Signature of parent/guardian: __________________________________
date: _______________
Parents are asked to remain on-site for practices and games to assume responsibility for their child in case of injury.
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