STOWE SOCCER CLUB

2012 MEDICAL RELEASE FORM

Instructions:  Please print and complete a separate form for each child and return completed form to your child’s coach prior to first training session or game.

Player’s Name: _______________________________________                 School Grade:  ______

Male / Female: _________              Age: ___________                      Date of Birth: _____/_____/______

Parent / Guardian Name and Contact Information:         

Name: ____________________     Home: _____________           Work: _____________            Cell:_____________

Name: ____________________     Home: _____________           Work: _____________            Cell:_____________

Home Mailing Address:

____________________________________________________________________________________________

Email Address(s):

Name: ______________________    Email: ____________________________________________________           

Name: ______________________    Email: ____________________________________________________

Emergency Contact Information (other than parent /guardian):

Name: ____________________     Home: _____________           Work: _____________            Cell:_____________

Relationship to child:  ___________________________________

Player’s Doctor:  ________________________________________ Phone: _______________________

Primary Medical Insurance Company:  ___________________________________________________

Known allergies or other pertinent medical information:

Recognizing the possibility of physical injury associated with soccer and in consideration for Stowe Soccer Club (SSC), Vermont Soccer Association (VSA), US Youth Soccer  (YSYS) / US Soccer Federation (USSF) and it’s affiliates accepting the registrant for its soccer programs and activities (the “Programs”) I hereby release, discharge and/or otherwise indemnify SSC, VSA, USYS/USSF and the Stowe Soccer Club, their affiliated organizations and sponsors, and their officers, employees, volunteers, and all associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant’s 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 Stowe Soccer Club volunteers 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:_______________