Washington Medical Release Form 3
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Washington Premier F.C.
201 Valley Ave NW, Unit C
Puyallup, WA 98371

Medical Release Form
*Last Name
First Name
Middle
Nickname (If different than above)
Gender: Male
Address
City
Phone
Alt Phone
E-mail address
Birthdate
School
Grade
Returning Player?
Yes
No, If no, Last Year’s Team
Club
Association
Team #
(Please attach a copy of birth certificate w/seal to this form. * Name must match birth certificate)

Female (please circle)
Zip

Emergency Information
Father’s Name:
Home Phone:
Work Phone:
Mother’s Name:
Home Phone:
Work Phone:
In an emergency when parents cannot be reached, please contact:
Name:
Home Phone:
Work/Cell Phone:
Name:
Home Phone:
Work/Cell Phone:
Allergies:
Date of Last Tetanus:
Other Medical Conditions
Players Physician
Phone:
Medical and/or Hospital Ins Co
Phone
Policy Holder
Policy #
Group #
Please copy both sides of your medical insurance card # attach to this form
Parents approval and Medical Release
I, the parent/guardian of the registrant, a minor, agree that I