Player's Full Name:________________________________________Date of Birth:___________ Address:_______________________________________________________________________ City:__________________________________State:_____________________Zip:___________ Telephone:_____________________________School:__________________________________
The above soccer player has been granted permission to attend and participate in and with teams, leagues, tournaments, camps, and other soccer activities sponsored by the United States Youth Soccer Association, the Iowa Sate Youth Soccer Association or it's affiliated teams, clubs, or organizations.
The player has received a physical examination by a physician and is physically fit to participate.
In exchange for the privilege of the player participating in these activities, I waive any legal claim against those associated with these soccer activities in the event the player is injured while participating in these soccer activities, and travel to and from the same.
I hereby give my consent, in case of injury, to have an athletic trainer, doctor, nurse, hospital, or clinic provide the player with medical assistance and/or treatment, and agree to be responsible financially for the reasonable cost of such assistance and /or treatment.
__________________________Date:_______ __________________________Date:_______ Signature of Parent/Guardian Signature of Parent/Guardian Father's Name:___________________________Mother's Name:_________________________ Home Phone:_____________________________Home Phone:___________________________ Work Phone:_____________________________Work Phone:____________________________ In an emergency, when parents cannot be reached, please contact: Name:___________________________________Phone:________________________________ PERSONAL INFORMATION Height:_________________Weight:__________________ Any Allergies or physical problems:_________________________________________________ Any regular medications:__________________________________________________________ Doctor's Name:___________________________Phone:_________________________________ Hospital of Preference:_____________________Insurance Carrier:________________________