Copy both sides of your health insurance card and attach them to the form.
What you’ll need
Player
- Name
- Date of birth
- Gender
- Address, city, state and zip
Parents
- Father’s name, home and work phone
- Mother’s name, home and work phone
Emergency contacts
- Two people to call when parents cannot be reached
- A home and work phone for each
Medical
- Allergies
- Other medical conditions
- Player’s physician, with home and work phone
Insurance
- Medical and/or hospital insurance company and phone
- Policy holder
- Policy number and group number
Parent/guardian consent and medical release
Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the “Programs”), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son’s/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs.
My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child’s participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.
Signing
This page is for reading. A parent or guardian signs and dates the PDF, which is the copy the club keeps.
Download medical release & emergency contact (PDF)