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Missouri Emergency Medical Release Form

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

Missouri Emergency Medical Release Form
Missouri Emergency Medical Release Form
Player’s Name: __________________________________________________________________Birthdate: ___/___/___
Address: ________________________________________ City/State/Zip: ______________________________________
Father’s Name: __________________________________Phone Home (___) _____________Work: (___) ____________
Mother’s Name: _________________________________Phone Home (___) _____________Work: (___) ____________
In case of emergency when parent/guardian cannot be reached, please contact the following:
Name: ________________________________________Phone Home (___) _____________Work: (___) _____________
Allergies: ____________________________________Other Medical Conditions: ________________________________
Physician: _____________________________________Phone Home: (___) _____________Work: (___) _____________
Dentist: _______________________________________Phone Home: (___) _____________Work: (___) _____________
Medical/Hospital Insurance Company: ___________________________________________Phone (___) _____________
Policy Holder’s Name: __________________________________________Policy Number: _________________________
This authorization for emergency medical treatment must be completed before a player begins participation.
Treatment for injury will be based on information provided herein.
I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of the above listed minor
applicant/participant acknowledge and fully understand that each applicant/participant will be engaging in activities that involve
risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from
their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the
premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time,
assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death,
hereby release, discharge, covenants to indemnify and not to sue Missouri Youth Soccer Association, its affiliated organizations and
sponsors, their coaches, managers, employees and associated personnel, officers, directors, agents, including the owners and leasers
of premises used to conduct the event, all of which are hereinafter referred to as ‘releasees’, from any and all liability to each of the
undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant’s
participation in the Programs and/or being transported to or from the same, which participation, after careful consideration I hereby
authorize, and which transportation I hereby authorize. The applicant/participant has received a physical examination by a physician
and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer, coach
and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or
treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold
harmless and indemnify each and all parties herein referred to above as release form all liability, loss, cost, claim or damage
whatsoever, including death or damage to property, which may be imposed upon said release because of any defect in or lack of such
capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the release. I have read the above
waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily.
Signature of Parent or Guardian: _____________________________________________________Date: ____/____/____
Missouri Youth Soccer Association
Emergency Medical Release
& Liability Waiver
Missouri Emergency Medical Release Form