Authority to Treat and Waiver

**COACH: THIS COPY MUST COME WITH YOU TO THE FIELD! **

Player's Full Name_______________________________________ Telephone (   ) _______________

Address _________________________________ City _________________ State _____ Zip ________

Date of Birth __________________ Height _______________ Weight ________________

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.
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, medical doctor, nurse, hospital or clinic to 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.

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Signature of Parent / Guardian

___________________________________________
Signature of Parent / Guardian

Father: Home Phone (   )_____________________ Business Phone (   )_____________________

Mother: Home Phone (   )_____________________ Business Phone (   )_____________________

In an Emergency when parents cannot be reached, please contact:

Name ________________________________________________________________________

Relationship _______________________________ Phone (   )_____________________

ALLERGIES ___________________________________________________________________

MEDICAL PROBLEMS ____________________________________________________________

FAMILY PHYSICIAN ____________________________________________________________

INSURANCE CARRIER ___________________________________________________________

Subscribed and sworn to before me this __________________ day of _____________________

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Notary Public