IDAHO YOUTH SOCCER ASSOCIATION MEDICAL RELEASE FORM
Coach’s copy - to be carried by coach to all games and practices.
Player’s Name Address Parent/Guardian Name Parent/Guardian Address Parent/Guardian Home Phone Parent/Guardian Home Phone
Home Phone City/Zip Relationship City/Zip Work Phone Work Phone
Person To Notify In Case of Emergency
Home Phone Doctor To Notify In Emergency Hospital Preference, if any
Work Phone Phone City
List Any Medical Problems Or Conditions Player Has (include allergies and medications currently taking)
Family Insurance Information:
Insurance Company Address Subscriber Name Subscriber Number Subscriber Address
Child’s Birth Date City/State/Zip Do You Have A Dental Program Group Number City/Zip
I hereby give my consent for all medical care prescribed by a duly licensed Doctor of Medicine for the above minor as his/her parent or legal guardian. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my dependent. To the best of the undersigned’s knowledge, all of the above information is true and accurate.