UNITED STATES YOUTH SOCCER ASSOCIATION, INC.

A Division of United States Soccer Federation

KANSAS STATE YOUTH SOCCER ASSOCIATION

PLAYER MEDICAL RELEASE AND INFORMATION FORM

Player’s Name ________________________________________________ Date of Birth _____________________

Address _________________________________________City __________________ State ______ Zip ________

EMERGENCY INFORMATION

Father’s Name ________________________________ Home (_____) ______________ Work (____) ___________

Mother’s Name _______________________________ Home (____) ______________ Work (____) ___________

In an emergency when parents cannot be reached, please contact:

Name _______________________________________ Home (____) ______________ Work (____) ____________

Allergies _____________________________________________________________________________________

Other Medical Conditions _______________________________________________________________________

Player’s Physician _____________________________ Home (____) ______________ Work (____) ___________

Medical and/or Hospital Insurance Company _________________________________ Phone (____) ____________

Policy Holder ___________________________________________ Policy Number _________________________

PARENT’S APPROVAL AND MEDICAL RELEASE

Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/USYSA and it’s affiliates accepting the registrant for it’s soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, it’s 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 registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.

My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.

_________________________________________ _____________________

Signature of Parent/Guardian Date

Subscribed and sworn to before me this _________ day of _____________________________, ________________

_______________________________________________

Notary Public

My commission expires ________________

Revised 7-99 (Raised Seal of Original Stamp)