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Get Washington Youth Soccer Medical Release Form
Parent/Guardian Name: Home Phone: Work Phone: Parent/Guardian Name: Home Phone: Work Phone: In an emergency, when Parent/Guardian cannot be reached, please contact: Name: Home Phone: Work Phone: Name: Home Phone: Work Phone: Have you ever been rendered unconscious or suffered a concussion? Yes / No How many times? Date of last head injury: Have you ever suffered a back injury? Yes / No If yes, when and describe? Have you ever been diagnosed, by a Doctor, with any serious me.
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