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WISCONSIN YOUTH SOCCER ASSOCIATION EVENT MEDICAL RELEASE FORM 2013-2014 SEASON Player s Name Gender M Date of Birth MM/DD/YY F Club Mother s Name Home Phone Cell Phone Emergency Contact Doctor Emergency Phone Doctor Phone Medical Conditions Allergies IMPORTANT MEDICAL AND LIABILITY RELEASE MUST BE SIGNED Recognizing the possibility of injury or illness and in consideration for the Wisconsin Youth Soccer Association WYSA US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of WYSA US Youth Soccer and its members the Programs I consent to my son/daughter participating in the Programs. Further I release discharge and otherwise indemnify WYSA US Youth Soccer its member organizations and sponsors their employees associated personnel and volunteers including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of my player son/daughter as a result of my son s/daughter s participation in the Programs and/or being transported to or from the Programs which transportation I authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I give my consent to have an athletic trainer 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 each assistance and/or treatment. I agree that if it appears that my child may have sustained a concussion or head injury that he or she is to be removed from the completion until such time that a trained medical professional can examine them and approve their return to play soccer. In such case I understand that I am to provide a written clearance for my player to return to play soccer. registration that player is committed to the club for the seasonal year 8/1 7/31. The WYSA player transfer policy also takes effect at this time. Signature Date Addendum only for those players having sustained a possible concussion or head injury On date my player sustained a possible concussion or head injury. He/she has been examined by a trained medical professional and has been cleared to participate in soccer activities as of today. Further I release discharge and otherwise indemnify WYSA US Youth Soccer its member organizations and sponsors their employees associated personnel and volunteers including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of my player son/daughter as a result of my son s/daughter s participation in the Programs and/or being transported to or from the Programs which transportation I authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I give my consent to have an athletic trainer 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 each assistance and/or treatment.

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