MIME-Version: 1.0 Content-Type: multipart/related; boundary="----=_NextPart_01C9D982.8CC7CCD0" This document is a Single File Web Page, also known as a Web Archive file. If you are seeing this message, your browser or editor doesn't support Web Archive files. Please download a browser that supports Web Archive, such as Microsoft Internet Explorer. ------=_NextPart_01C9D982.8CC7CCD0 Content-Location: file:///C:/A3895E34/wscmedicalreleaseform071604.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Warrington Soccer Club

Warrington Soccer Cl= ub

Medical Release Form

 

Child’s Full Name        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;         Telephone (       )      = ;            &n= bsp;            = ; 

Address            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;            &n= bsp;            = ;     

City            =             &nb= sp;            =             &nb= sp;    State        &= nbsp;       Zip        &= nbsp;          Date= of Birth     &n= bsp;            = ;         

 

I hereby give my consent to those listed below, in case of accident, injury, = sickness, etc., to have an athletic trainer, medical doctor, nurse, hospital or clini= c to provide the player with medical assistance and / or treatment, and agree to= be financially responsible for the reasonable cost of such treatment and / or assistance.

 

1.  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;  

2.  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;  

3.  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;  

4.  =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;  

 

Father:    Home Phone (       )        &= nbsp;           &nbs= p;            &= nbsp;   Business Phone (        )        &= nbsp;           &nbs= p;            &= nbsp;

Mother:  Home Phone (        )        &= nbsp;           &nbs= p;            &= nbsp;   Business Phone (        )        &= nbsp;           &nbs= p;            &= nbsp;

Emergency Contact:  Name           &nbs= p;            &= nbsp;           &nbs= p;             = Phone (      &n= bsp; )      = ;            &n= bsp;            = ;      

Family Physician:        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;        Phone (        )        &= nbsp;           &nbs= p;            &= nbsp;   

ALLERGIES     &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;   

MEDICAL PROBLEMS        =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =         

INSURANCE CARRIER        &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;            &= nbsp;         Policy #      &nb= sp;            =             &nb= sp;  

 

            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          =         =             &nb= sp;            =         &nb= sp;            =             &nb= sp;            =             &nb= sp;   

Signature of Parent or Guardia= n        &= nbsp;           &nbs= p;            &= nbsp;          Signature of Parent or Guardian

 

<= st1:PlaceType w:st=3D"on">Commonwealth of Pennsylvania
County of= Bucks

On this ______day of ________________, personally appeared ____________________before me, the undersigned Notary Public

 

 

 

            &= nbsp;           &nbs= p;            &= nbsp;           &nbs= p;          =

Notary Public

 

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wsc medical release form 071604

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