Home
 
 
My my My my
 
 
 
 
 
 

 
Newtown Soccer Club, Soccer, Goal, Field

 

 

 

Player Information and Medical Release Form

 

 

 

Player’s Name____________________________________     Date of Birth_____________________

 

Address __________________________ City ______________ State _____________ Zip Code_________________

 

EMERGENCY INFORMATION:

 

Father’s Name____________________ Home Phone ___________________Work Phone_____________________

 

Mother’s Name___________________ Home Phone_____________________ Work Phone___________________

 

In an emergency when parents cannot be reached, please contact:

 

Name ___________________________Home Phone____________________ Work Phone___________________

 

Name___________________________ Home Phone_____________________ Work Phone___________________

 

Allergies

 

Other medical conditions______________________________________________________

 

Player’s Physician _______________________________Home Phone ___________________Work Phone______________

 

Medical and/or Hospital Insurance Company ___________________________Phone____________________

 

Policy Holder_____________________ Policy # ____________________Group #_________________________

 

PARENT’S APPROVAL AND MEDICAL RELEASE

Recognizing the possibility of physical injury associated with soccer and in consideration for the Newtown Soccer Club and its affiliates accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the Newtown Soccer Club, its affiliated organizations and sponsors, their employees and associated personnel, including the owner 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 has been found physically capable of participating in the Programs. I hereby 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.

 

 

 

____________________________                                               ___________________   

Signature of Parent or Guardian                                           Date