Alabama Player Medical Release Form
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Alabama Youth Soccer
A Division of ASA
PLAYER INFORMATION AND MEDICAL RELEASE FORM

Player's Name

Date of Birth

Address

City

State

Zip

H.S. Attending

U.S. Citizen: Yes_____ No

e-mail: _____________________________________

Expected H.S. Graduation Yr: ______

EMERGENCY INFORMATION
Father's Name__________________ Home Phone (____)____________ Work Phone (
Cell Phone (

)

email:

)

Mother’s Name _________________ Home Phone (____)____________ Work Phone (____)___________
Cell Phone (

email:

)

In an emergency when parents cannot be reached, please contact:
Name

Home Phone (____)_____________Cell (

Name _______________________

_

Home Phone (

)

Cell(

)
)

Allergies ______________________________________________________________________________
Other medical conditions __________________________________________________________________
Injuries in the past 12 months
Player's Physician____________________

Home Phone (____)___________Work Phone (____)_________

M