Pennsylvania Medical Release Form 3
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Eastern Pennsylvania Youth Soccer Association

Two Village Road, Suite 3, Horsham, PA 19044
Phone (215) 657-7727 • Fax (215) 657-7740 • www.epysa.org

Medical Release
Player’s Name: ___________________________________________ Date of Birth: _______ / _______ / _______
Address: _________________________________________________________________________________________
City: _______________________________________________

State: __________ Zip: _________________

EMERGENCY INFORMATION (Please include Area Code)
Father’s Name: _________________________________ Mother’s Name: _________________________________
Father’s Home Phone: (

) ____________________ Mother’s Home Phone: (

) ____________________

Father’s WorkPhone: (

) _____________________ Mother’s WorkPhone: (

) ____________________

Father’s Cell Phone: (

) _____________________ Mother’s Cell Phone: (

) _____________________

Father’s E-mail: _________________________________ Mother’s E-mail: ________________