Medical Release Form – FC New Olreans-Youth Soccer Club

Football Club of New Orleans

5107 Venus Street

New Orleans, Louisiana 70122

504.288.6672 info@fcnola.com

MEDICAL RELEASE AUTHORIZATION

Player's First Name *

First

Player's Last Name *

Last

Date of Birth

Gender

Male

Female

Address *

Address Line 2

City *

State *

Postal Code

Country *

FATHER'S FULL NAME

HOME NUMBER

MOBILE NUMBER

MOTHER'S FULL NAME

HOME NUMBER

MOBILE NUMBER

In an emergency, when parents cannot be reached, please contact:

Emergency Contact Primary

Home Number

Work Number

Mobile Number

Emergency Contact Secondary

Home Number

Work Number

Phone Number

Allergies

Other Medical Conditions

Player's Physician's Full Name

Home Number

Work Number

Mobile Number

Medical and/or Hospital Insurance Company

Phone Number

Policy Holder

Policy Number

Group Number

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND UPLOAD

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. Further, I
hereby release, discharge, and otherwise indemnify US Youth Soccer, its member organizations and sponsors,
their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for
the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s
participation in the Programs and/or being transported to or from the Programs. I hereby authorize the
transportation of my son/daughter to or from the Programs.
My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

INSURANCE CARD UPLOAD

Maximum upload size: 25MB

Parent/Guardian Signature Electronic *

Date

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