Vermont Soccer Association
Medical Release Form
Players Name:__________________________________U.S. Citizen† Yes____No____
Parentís Phone Home:_______________________† Work: ______________________
Email Address: _________________________________________________________
Emergency phone number other than Parent/Guardian
Name:___________________________________ Phone: _______________________
Primary Medical Insurance Company: _______________________________________
Policy Number: _________________________________________________________
Known allergies or other pertinent medical information: _________________________
Recognizing the possibility of physical injury associated with soccer and in consideration for USYS/USSF and itís affiliates accepting the registrant for its soccer programs and activities (the ďProgramsĒ) I hereby release, discharge and/or otherwise indemnify USYS/USSF, itís affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrantís participation in the Programs, and/or being transported to or from the same, which transportation I hereby authorize.† My child has received a physical examination by a physician and has been found physically capable of participating in the Programs.
Therefore, I grant___________________________and/or_________________________
Permission to act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or dentistry.† I also assume the financial responsibility for any medical treatment for my child.
Signature of Parent/Guardian:____________________________Date:_______________