Missouri Emergency Medical Release Form
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Missouri Youth Soccer Association
Emergency Medical Release
& Liability Waiver
Player’s Name: __________________________________________________________________Birthdate: ___/___/___
Address: ________________________________________ City/State/Zip: ______________________________________
Father’s Name: __________________________________Phone Home (___) _____________Work: (___) ____________
Mother’s Name: _________________________________Phone Home (___) _____________Work: (___) ____________
In case of emergency when parent/guardian cannot be reached, please contact the following:
Name: ________________________________________Phone Home (___) _____________Work: (___) _____________
Allergies: ____________________________________Other Medical Conditions: ________________________________
Physician: _____________________________________Phone Home: (___) _____________Work: (___) _____________
Dentist: _______________________________________Phone Home: (___) _____________Work: (___) __________