Portland High School Co-ed Soccer Club
2008 Player Medical Consent Form
Please Print Clearly
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PLAYER INFORMATION
__________________________ ____________________________ __/__ __/__ __ ___ ___
First Name Last Name Birth Date M F
____________________________________________ ________________________ _________
Street Address City Zip Code
____________________________ ___________________________________________________
Telephone Number Email Address
_________________________________________________________________________
Describe any medical problems
_____________________________ ____________________ ____________________________
Physician’s Name Telephone Hospital Preference
______________________________________________________ ____________________________
Insurance Company Name Identification Number
RELEASE FROM LIABILITY
I, the parents/guardian of the registrant, agree that I and the registrant will abide by the rules of the USYSA, its
affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer, and
in consideration for the USYSA accepting the registrant for its soccer programs and activities (the “Program”, I
hereby release, discharge, and/or otherwise indemnify the USYSA, its 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 registrant’s participation in the
Programs and/or being transported to or from the same, which transportation I hereby authorize.
______________________________________________________ ____________________________
Name of Parent/Legal Guardian (Please Print) Telephone
______________________________________________________ ____________________________
Signature Date
CONSENT FOR MEDICAL TREATMENT
As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care
prescribed by a duly licensed Doctor of Medicine or Doctor in Dentistry. This care may be given under
whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
__________________________________________________ _________________________
Name of Parent/Legal Guardian (Please Print) Telephone
__________________________________________________ _________________________
Signature Date