South Carolina Medical Release Form 2
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South Carolina Youth Soccer
Medical Release Form
Function: _______________________________________________________________________________
Player’s Name: __________________________________________________________________________
Address: _______________________________________________________________________________
City/State/Zip Code: ______________________________________________________________________
Birthdate: _______________________________________ Sex: ___________________________________
Home Phone: ____________________________________ Alternate Phone: _________________________
Email: __________________________________________ Alternate Email: __________________________
Parent/Guardian
Cell Phone
Home Phone
Work Phone
_________________________________

_______________

_______________

_______________

_________________________________
_______________
Contact Type
Name

_______________

_______________
Phone

Emergency Contact:

___________________________________

___________