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Get Mysa Medical Waiver

Only players participating in the US Youth Soccer Minnesota State Cup or an out-of-state tournament need to have this form notarized unless required by your club. LIABILITY/MEDICAL RELEASE Player s Name Date of Birth Address City ST Zip EMERGENCY INFORMATION Parent/Guardian Name Home Ph Work Ph Allergies Other Medical Conditions Phone Medical Insurance Company Policy Number Policy Holder Player s Physician In an emergency when parent/guardian cannot be reached please contact Name PLAYER OR PARENT/GUARDIAN AGREEMENT I as the adult-age player or the parent/guardian of the registered minor player agree to abide by the rules of the Minnesota Youth Soccer Association MYSA US Youth Soccer and its affiliated organizations and sponsors. MINNESOTA YOUTH SOCCER ASSOCIATION INC. www. mnyouthsoccer. org IMPORTANT Please send the completed form to the club you are registering with not MYSA. Only players participating in the US Youth Soccer Minnesota State Cup or an out-of-state tournament need to have this form notarized unless required by your club. LIABILITY/MEDICAL RELEASE Player s Name Date of Birth Address City ST Zip EMERGENCY INFORMATION Parent/Guardian Name Home Ph Work Ph Allergies Other Medical Conditions Phone Medical Insurance Company Policy Number Policy Holder Player s Physician In an emergency when parent/guardian cannot be reached please contact Name PLAYER OR PARENT/GUARDIAN AGREEMENT I as the adult-age player or the parent/guardian of the registered minor player agree to abide by the rules of the Minnesota Youth Soccer Association MYSA US Youth Soccer and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the MYSA and US Youth Soccer accepting the player for its soccer programs and activities I hereby release discharge and/or otherwise indemnify the MYSA US Youth Soccer and 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 program and/or being transported to or from the same which transportation I hereby authorize. Adult Player or Parent/Legal Guardian of Minor Player Print Date Signature CONSENT FOR MEDICAL TREATMENT As the adult player or parent/legal guardian of a minor participant in MYSA/US Youth Soccer programs I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life limb or well-being of the player. Signed or acknowledged before me this day of 20 Notary Public My commission expires Raised seal or original stamp Revised 1/14/08. MINNESOTA YOUTH SOCCER ASSOCIATION INC. www. mnyouthsoccer. org IMPORTANT Please send the completed form to the club you are registering with not MYSA. Only players participating in the US Youth Soccer Minnesota State Cup or an out-of-state tournament need to have this form notarized unless required by your club.

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