Indiana Medical Release Form 1
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United Soccer Alliance of Indiana Medical Release Form
As the parent/legal guardian of
, I Request that in my absence the above-named player
be admitted to any hospital facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed
as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures,
treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee
as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from
the above-named player.

Date of Players Birth

/

/

Date of last Tetanus Booster

/

/

Known allergies of this player, including any allergies to medicine

Any other medical problems which should be noted

Family Physician

Phone ( )

Name of Parent/Guardian
Address

City/State/Zip

Phone ( )

H(

)

W()

F

Person responsible fo