New Jersey Youth Soccer Medical Release Form
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New Jersey Youth Soccer
Medical Release Form

Player’s Name

Date of Birth

Address

Gender

Town

State

M

F

Zip Code

Contact Information
Father’s Name
Mother’s Name

Home Phone
Home Phone

Work Phone
Work Phone

In an emergency when parents cannot be reached, please contact:
Name

Home Phone

Work Phone

Medical Information
Allergies
Other medical conditions
Player’s Physician

Phone

Primary Medical Insurance Company
Policy Holder

Policy #

Group #

PARENT’S APPROVAL AND MEDICAL RELEASE
Recognizing the possibility of physical injury associated with soccer and in consideration for New Jersey Youth Soccer accepting the
registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the New
Jersey Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields
and facilities utilized for the Programs against any claim by or on behalf of the registrant as a res