MEDICAL RELEASE FORM

MEDICAL RELEASE FORM
CHILD’S NAME _____________________________ D.O.B. ___________________
GENDER:
BOYS / GIRLS
DIVISION: U10 / U12 / U14 (Please Circle)
EMERGENCY AUTHORIZATION: I, the undersigned parent or legal guardian of the above player, a minor, hereby
authorize the coaches, team parents, the above-identified Emergency Contact and/or other American Youth Soccer
Organization (“AYSO”) officials to act as my agents in the capacity of activity supervisors and vehicle drivers, and to
consent to medical, surgical or dental examination and/or treatment.
DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I, the undersigned parent of legal guardian of the above
player, a minor, for myself and on behalf of the above player, our heirs, assigns and the next of kin, acknowledge that
participation in soccer necessarily involves travel, play in adverse field conditions, contact with considerable force, and
risk of severe, permanent physical injury including bruises, scrapes, strained, sprained or torn muscles, tendons or
ligaments, broken bones, dislocation of joints, concussion, brain damage, nerve and spinal cord injury, paralysis and
death. For myself, and on behalf of the above player, our heirs, assigns and next of kin, we willingly and voluntarily
accept and assume all such risk.
For myself and on behalf of the above player, I further acknowledge that AYSO is primarily administered by volunteers
rather than paid professionals. For myself and on behalf of the above player, he/she and I willingly and voluntarily
agree to comply with the stated and customary terms and conditions for participation and, if he/she or I observe any
unusual significant concern in his/her readiness for participation and/or in the program itself, I will remove him/her
from participation and bring such concern to the attention of the nearest official immediately and also of the regional
commissioner as soon as possible thereafter.
In consideration of AYSO’s accepting the registration and permitting the voluntary participation of the above-named
participant in its programs, for myself and on behalf of the above player, our heirs, assigns and next of kin, I hereby
release, discharge and agree to hold harmless AYSO, its employees, volunteers, officials, sponsors and other
representatives from any and all claims, demands, costs, expenses and compensation arising out of or in any way
related to any injury or other damage that may result to said participant while participating in any AYSO-sponsored
event, including any physical or other injury caused by the negligence of any such person while performing his/her
duties at any time.
ACKNOWLEDGEMENT AND CONSENT: I acknowledge receipt of the Soccer Accident Insurance pamphlet and I
understand the terms of the Plan. For both internal and external use, I acknowledge that AYSO may compile and use
addresses and soccer photographs of the named individual. I consent to such uses and hereby waive all rights to
compensation.
I HAVE READ THE ABOVE EMERGENCY AUTHORIZATION, DISCLAIMER, ASSUMPTION OF RISK AND
WAIVER, AND ACKNOWLEDGEMENT AND CONSENT AGREEMENTS, FULLY UNDERSTAND THE
TERMS OF EACH, UNDERSTAND THAT I AND THE ABOVE PLAYER HAVE GIVEN UP SUBSTANTIAL
RIGHTS BY MY SIGNING THIS
FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS
FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT FOR MYSELF AND ON BEHALF OF THE
ABOVE PLAYER.
Date____/_____/_______Signed: ________________________________________
PRINTED NAME: ________________________________________
PRINTED E-MAIL ADDRESS: _________________________________________