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:________________________