medrelease

TUPELO YOUTH SOCCER ASSOCIATION
TUPELO FUTBOL CLUB
Medical Release Form

Player Name:____________________________________ DOB:__________________ Sex:_________

Address:____________________________________________________________________________

City, State, Zip:_______________________________________________________________________

Parent Name:________________________________________________________________________

Parent Phone (H)_______________________________ (W)__________________________________

In cases of emergency, call (other than parent)

Name:_____________________________________ Phone:__________________________________

Name of Insurance / Group:___________________________________________________________

Policy ID#::________________________________ Group #__________________________________

Any Allergies or other medical information:

___________________________________________________________________________________

This is to certify that my child has my permission to participate in practice, games, tournaments or other activity as a member of the Tupelo Futbol Club. As the parent/guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed doctor. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. Additionally, I hereby grant authority to any qualified medical facility to render such treatment and to admit above named person as is deemed necessary under the circumstances. In witness of our consent and agreement to the medical authorization specified herein, we have subscribed our signature on the ____________ day of ____________________, 20_______.

Parent:___________________________________ Witness:_________________________________

Notary:______________________________________ Date:_________________________________