Medical Waiver - Lockport Soccer Club

Tournament Player Information / Medical Consent and Release Form

Player Name*
Parent/Guardian Full Name*
Address*
Street Address Address Line 2 City State ZIP Code
Players Date of Birth*
Month
Day
Year
Head Coach*
Known allergies of this player including allergies to medicine?*
Any other medical conditions or medications? (dosages)*
Family Physician*
Physician's Phone*
Insurance Carrier*
Insurance Policy Number*
Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/USYSA and its affiliates accepting the registrants for its soccer programs and activities (the“Programs”), I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including owners of the 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 consent for medical treatment if necessary and agree to be responsible financially for the reasonable cost of such assistance and/or treatment. The undersigned, being the parent or legal guardian of the above named player, in the event of injury or illness, herby give my consent to have an Athletic Trainer, Emergency Medical Technician, Physician, Hospital, Dentist or other appropriate medical personnel provide him/her with medical assistance and/or treatment.
Parent/Guardian Signature*
Date*
MM slash DD slash YYYY
Emergency Phone*
Contact Email*
Name
This field is for validation purposes and should be left unchanged.