North Carolina Medical Release Form 1
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NORTH CAROLINA Medical Consent / Waiver of Liability and Release
(To be given to your local association)
20 ____ - 20____

NCYSA

NCYSA Policy #
Excess policy to any valid and collectible
insurance. If there is no primary insurance on
insurance on a player, this policy is
primary after the deductible.

PO Box 18229
Greensboro, NC 27419
336.856.7529

Player First Name
M Initial
Last Name
(AS APPEARS ON BIRTH CERTIFICATE)

Full Association Name
[ ] Academy

[ ] Challenge

Birth Date

[ ] Classic

Jersey #
[ ] Recreation

[ ] Male

Level

[ ] Female
Sex

Address of Player

City

State

Zip

Parent/Legal Guardian Full Name

Home Phone

Work Phone

Cell Phone

Additional Person to Contact in an Emergency

Address

Home Phone

Cell Phone

Date of Last Tetanus Shot

Medications now being taken

Player is Allergic to these Medications and Substances
Parent Email For Soccer Information

List any Unusual Health Information

I (we), the undersigned, residing in the county of
, state of _________,