South Carolina Medical Release Form 3
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SOUTH CAROLINA UNITED BATTERY DA

PLAYER INFORMATION AND MEDICAL RELEASE FORM
Boys: Age Group (circle one): U16

U18

Player’s Name ___________________________________________________________ DOB _____________________
Address ____________________________________________________________________________
City _____________________________________________________________
Email

___________________________________________

State_______ Zip _________________

Email __________________________________________

EMERGENCY INFORMATION

Father’s Name _________________________________________________________ Daytime # (______)______________
Cell # (______)__________________________

Evening # (______)_________________

Mother’s Name ________________________________________________________ Daytime # (______)______________
Cell # (______)__________________________

Evening # (______)_________________

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