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Medical Release

You are welcome to use your own Medical Release Form.

  
Medical Release Form

Western Lehigh United Soccer Club

Medical Release Form
 
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:   ____________________________   Cell Phone:________________________
 
Dad's Work #:____________________________ _ Mom's Work #: ______________________
 
Player's Birthdate:________________________
 
Medical Information for Player:
 
Insurance Company:    ____________________________ Policy #:________________________
 
Physician :___________________________________
 
Address: _______________________________________________________________________
 
Allergies:_______________________________    Current medications:________________________
                                                                                                        
                                                                                                                                             _______________________
 
Other Medical Conditions:________________________________________________________
 
                                               ________________________________________________________
 
In the event I cannot be reached immediately, anyone of the following persons are 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 or a manager. Then make a copy for each player to fill out.
 
1. Name________________________   Address______________________________________
 
2. Name________________________   Address______________________________________
 
3. Name________________________   Address______________________________________
 
 
Parent Signature __________________________     Print Name ___________________________
 
Date ________________________
    
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