Blue Ridge Youth Soccer

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Blue Ridge Youth Soccer Association

Medical Release

Note: To be carried by any Regular Season or Tournament Team Manager together with team roster or eligibility affidavit.

Player: ______________________________

Date of Birth: ______________________

League Name: Blue Ridge Youth Soccer

I.D. Number _________________________

In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by CERTIFIED EMERGENCY PERSONNEL. (i.e. EMT, First Responder, E.R.Physician)

Family Physician _____________________

Phone Number _______________________

Physician's Address ________________________________________________________________

Hospital Preference _________________________________________________________________

In case of emergency Contact:

Name

Phone #

Relationship to Player

Name

Phone #

Relationship to Player

Please list any allergies / medical problems, including those requiring maintenance medication. (i.e. Diabetic, Asthma, Seizure Disorder)

Medical Diagnosis

Medication

Dosage

Frequency of Dosage

The purpose of the above-listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Date of last Tetanus Toxoid Booster: ________________________

Authorized Parent / Guardian Signature _______________________________ Date ___________

Warning: Protective equipment cannot prevent all injuries a player might receive while participating in soccer.

Blue Ridge Youth Soccer does not limit participation in its activities on the basis of disability, race, color, creed, national origin, gender, sexual preference, or religious Preference.