Fillable Ayso Extra Medical Release Form printable pdf download

MEDICAL RELEASE FORM

CHILD’S NAME _____________________________ D.O.B. ___________________

GENDER: BOYS / GIRLS

DIVISION: U10 / U12 / U14 (Please Circle)

EMERGENCY AUTHORIZATION: I, the undersigned parent or legal guardian of the above player, a minor, hereby

authorize the coaches, team parents, the above-identified Emergency Contact and/or other American Youth Soccer

Organization (“AYSO”) officials to act as my agents in the capacity of activity supervisors and vehicle drivers, and to

consent to medical, surgical or dental examination and/or treatment.

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I, the undersigned parent of legal guardian of the above

player, a minor, for myself and on behalf of the above player, our heirs, assigns and the next of kin, acknowledge that

participation in soccer necessarily involves travel, play in adverse field conditions, contact with considerable force, and

risk of severe, permanent physical injury including bruises, scrapes, strained, sprained or torn muscles, tendons or

ligaments, broken bones, dislocation of joints, concussion, brain damage, nerve and spinal cord injury, paralysis and

death. For myself, and on behalf of the above player, our heirs, assigns and next of kin, we willingly and voluntarily

accept and assume all such risk.

For myself and on behalf of the above player, I further acknowledge that AYSO is primarily administered by volunteers

rather than paid professionals. For myself and on behalf of the above player, he/she and I willingly and voluntarily

agree to comply with the stated and customary terms and conditions for participation and, if he/she or I observe any

unusual significant concern in his/her readiness for participation and/or in the program itself, I will remove him/her

from participation and bring such concern to the attention of the nearest official immediately and also of the regional

commissioner as soon as possible thereafter.

In consideration of AYSO’s accepting the registration and permitting the voluntary participation of the above-named

participant in its programs, for myself and on behalf of the above player, our heirs, assigns and next of kin, I hereby

release, discharge and agree to hold harmless AYSO, its employees, volunteers, officials, sponsors and other

representatives from any and all claims, demands, costs, expenses and compensation arising out of or in any way

related to any injury or other damage that may result to said participant while participating in any AYSO-sponsored

event, including any physical or other injury caused by the negligence of any such person while performing his/her

duties at any time.

ACKNOWLEDGEMENT AND CONSENT: I acknowledge receipt of the Soccer Accident Insurance pamphlet and I

understand the terms of the Plan. For both internal and external use, I acknowledge that AYSO may compile and use

addresses and soccer photographs of the named individual. I consent to such uses and hereby waive all rights to

compensation.

I HAVE READ THE ABOVE EMERGENCY AUTHORIZATION, DISCLAIMER, ASSUMPTION OF RISK AND

WAIVER, AND ACKNOWLEDGEMENT AND CONSENT AGREEMENTS, FULLY UNDERSTAND THE

TERMS OF EACH, UNDERSTAND THAT I AND THE ABOVE PLAYER HAVE GIVEN UP SUBSTANTIAL

RIGHTS BY MY SIGNING THIS

FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS

FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT FOR MYSELF AND ON BEHALF OF THE

ABOVE PLAYER.

Date____/_____/_______Signed: ________________________________________

PRINTED NAME: ________________________________________

PRINTED E-MAIL ADDRESS: _________________________________________

Ayso Extra Medical Release Form