Kansas Player Information and Medical Release Form
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United States Youth Soccer Association, Inc.
A division of United States Soccer Federation

KANSAS STATE YOUTH SOCCER ASSOCIATION
Player Information and Medical Release Form

Player’s Name______________________________________________________ Date of Birth ____________________
Address ______________________________________________City ________________ State _______ Zip ________
EMERGENCY INFORMATION
Father’s Name ___________________________________ Home Phone (____)_________Work Phone (____)_________
Mother’s Name __________________________________ Home Phone (____)_________Work Phone (____)_________
In an emergency when parents can’t be reached, please contact:
Name ________________________________________ Home Phone (____)__________Work Phone (____)__________
Name ________________________________________ Home Phone (____)__________Work Phone (____)__________
Allergies __________________________________________________________________________________________
Other Medical Conditions _