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Medical Release
You are welcome to use your own Medical Release Form.
Don't forget - the forms must be notarized!
  
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
    
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