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Get Arkansas State Soccer Association Player Information And Medical Release Form

Arkansas State Soccer Association Player Information and Medical Release Form This is not a registration form. Return this form to local association This form should stay with the team manager or coach Seasonal Year Player s Name Date of Birth Address Father s Name City State Emergency Information Home Phone Zip Work/Cell Phone In an emergency when parents cannot be reached please contact Name Allergies Other medical conditions Player s Physician Phone Medical and/or Hospital Insurance Company Policy Holder Policy Group PLEASE COPY BOTH SIDES OF YOUR MEDICAL INSURANCE CARD ATTACH TO THIS FORM PARENT S APPROVAL AND MEDICAL RELEASE Recognizing the possibility of physical injury associated with soccer and/or the sudden illness at an event and in consideration for the USSF/USYSA and its affiliates accepting the registrant 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 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 had been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer emergency personnel 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. It is highly recommended that this form is notarized if the player attends out-of-state tournaments/events. participating in ASSA state events ODP AR State League President s Cup AR State Championships Signature of Parent/Guardian Notarization is required for players Date Notary Subscribed and sworn to before me thisday of 20 My commission expires raised seal or original stamp. My son/daughter has received a physical examination by a physician and had been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer emergency personnel 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. I hereby give my consent to have an athletic trainer emergency personnel 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. It is highly recommended that this form is notarized if the player attends out-of-state tournaments/events. It is highly recommended that this form is notarized if the player attends out-of-state tournaments/events. participating in ASSA state events ODP AR State League President s Cup AR State Championships Signature of Parent/Guardian Notarization is required for players Date Notary Subscribed and sworn to before me thisday of 20 My commission expires raised seal or original stamp.

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