Western Lehigh Four Game Fall Fest > Acceptance

Medical Release Form

Western Lehigh United Soccer Club
MEDICAL RELEASE

I hereby give my permission for any and all medical attention necessary to be administered to my child, ________________________________, in the event of any accident, injury, sickness, etc., under the direction of one of the persons listed below, until such time as I may be contacted. I also hereby assume the responsibility for payment of any such treatment.

Parent(s) or Legal Guardian(s):
Address:
Home Phone:
Player's Social Security #:				Dad’s Work #:
Player's Birth Date:				Mom’s Work #:

Medical Information for PLAYER:
Insurance Company:				Policy # :
Physician:
Address:
Allergies:			Current Medications:
Other Medical Conditions


In the event I cannot be reached immediately, any one of the following persons is designated to act on my behalf:

NAME, Phone Number and Home Address of at least 2 people who will be with the player at the event. (Please Print Clearly)
Typically the coach will fill in his name and his 2 assistants/managers then make a copy for each player to fill out and notarize

1

2

3


Subscribed and sworn (or affirmed) to				Parent or Legal Guardian
me this	day of	,
				Signature
Notary’s Signature				Date:	/ /
					Month	Day	Year