Free Idaho Medical Release Form PDF Download

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.

Signed Date

Revised 6/21/07

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