Michigan Medical Release Form 2
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West Michigan Youth Soccer Association

Please print all information except signature
I,______________________________________ hereby give my permission for any and all medical
attention necessary to be administered to my child (name)____________________________________
in the event of accident, injury or illness, 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 such treatment.
My address is: ______________________________________________________________________
Home Phone: (

) ___________________________ Office: (

) ________________________

My insurance company is: _____________________________________________________________
My policy number is: _________________________________________________________________
In case I cannot be reached, any of the following is designated to act in my behalf