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PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM Player’s Name: Date of Birth: Gender: Address: City: State: 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 Phone: Name: Home Phone: Work Phone: Allergies: Other Medical Conditions: Player’s Physician: Home Phone: Work Phone: Medical and/or Hospital Insurance Company: Phone: Policy Holder: Policy : Group : PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS FORM PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent to my son/daughter participating in the Programs..
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