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Minnesota Emergency Information Consent Form

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This form is provided by Minnesota Youth Soccer Association for the emergency medical information release regarding the medical care and treatment necessary to be administered to the player.

Minnesota Emergency Information Consent Form
Minnesota Emergency Information Consent Form
MINNESOTA YOUTH SOCCER ASSOCIATION
Emergency Information Consent Form
Name of Registrant _______________________________ _______ ___________________________________
First Initial Last
Club ________________________ Team Name ____________________________________________________
Parent/Guardian Agreement
I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the USYSA and
the MYSA, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer
and in consideration for the USYSA and MYSA accepting the registrant for its soccer programs and activities (the
“programs”), I hereby release, discharge and/or otherwise indemnify the USYSA and MYSA, its affiliated organizations
and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the
Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs
and/or being transported to or from the same, which transportation I hereby authorize.
Parent/Legal Guardian (Please Print) ___________________________________________
Date ____________________________ Signature X ____________________________________________
Emergency Information
__________________________________ _____________________________________ _______________
Who should be notified Street Address Home Phone
__________________________________ _____________________________________ _______________
Alternate who can be notified Street Address Home Phone
__________________________________ _____________________________________ _______________
Physician/HMO/Clinic Name Street Address Work Phone
__________________________________ _____________________________________
Medical Insurer Medical Policy Number
__________________________________ _____________________________________
Dentist Name Work Phone
__________________________________ _____________________________________
Dental Insurer Dental Policy Number
________________________________________________________________________
List any medical problems, limitations, or prohibitions the player may have
Consent for Medical Treatment
As the parent or legal guardian of a participant in USYSA-MYSA programs, I hereby give my consent for emergency
medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under
whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
Date _____________________________ Signature X _____________________________________
Notes:
1. Adults and high school graduate players over age 18 who are not claimed as dependents by their parents may sign
this form for themselves.
2. This form, a portion of the MYSA individual registration form, is to be retained by each team for such use as may be
required during the MYSA season.
3. If the player wears eyeglasses during play, lenses and frames of a type acceptable to the referee must be provided at
the player’s responsibility.
Minnesota Emergency Information Consent Form