Player Medical Form - Chesapeake United Soccer Club
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1CUSC PLAYER MEDICAL FORM
This form must be completed by player’s parent/guardian and
maintained by Coach/Team Manager for Soccer Season
Team Name:
Year/Group:
Coach:
PLAYER INFORMATION
Name:
Birth Date:
Gender:
Male
Female
Address:
City:
State:
Zip:
Email:
PARENT/GUARDIAN CONTACT INFORMATION
Parent:
Cell:
Receive Texts?
Yes
No
Email:
Home:
Work:
Parent:
Cell:
Receive Texts?
Yes
No
Email:
Home:
Work:
EMERGENCY CONTACT INFORMATION
Name:
Phone #1:
Phone #2:
Name:
Phone #1:
Phone #2:
PLAYER’S MEDICAL INFORMATION
Physician:
Phone #1:
Phone #2:
Insurance Co:
Policy #:
Phone No:
Group#:
Please list
player’s
allergies:
Please
list other
medical
conditions:
MEDICAL TEATMENT AUTHORIZATION
As the parent/legal guardian of ____________________________________________________, born ________________________,
I hereby give my consent and permission for the player named below to be medically and/or surgically treated for injuries and/or illness
of any kind or seriousness under the direction of Team Officials with a valid USYS Member Pass, until such time as I can be contacted.
Further, I give my consent and permission to the physician and/or hospital and/or other health care provider selected to provide medical
or surgical treatment, including, without limitation, dental care, hospitalization, injection, anesthesia, invasive surgery or any other form
or kind of medical or surgical care (emergency or otherwise) for the player.
Relation
Signature:
Date:
to Player:
NOTE: For the Advanced Program, this form does not have to be notarized.
Sworn to and subscribed before me on:
Notary Public in and for the State of:
Notary Name:
My Commission Expires:
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