Michigan Soccer Medical Release Form
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THIS FORM MUST BE PRINTED OR TYPED
MSYSA STATE OFFICE - 9401 GENERAL DRIVE, SUITE 120, PLYMOUTH, MI 48170.

SOCCER MEDICAL RELEASE
CASH WILL NOT BE ACCEPTED. CHECKS MUST BE MADE PAYABLE TO MSYSA.

I hereby give my permission for any and all medical attention necessary to be administered to my child,
(INSERT CHILD’S NAME)

In the event of accident, injury, sickness, etc., under the direction of the person(s) listed below, until such time as I may be
contacted, this release is effective for a period of one year from the date given below. I also assume the responsibility for the
payment of any such treatment, including, but not limited to transportation for required treatment.
Parent/Guardian:
Address:
Relationship:
City/State/Zip:
Home Phone:
Office Phone:
Cell Phone:
Name of Insurance Company:
Agent:
Policy Number:

Type:

In case I cannot be reached, any of the following people are designated to act on my behalf:
1. Coach.

2. Assistant Coach/Manager

3. Team Parent

4. A league repres