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 ________________________