It’s Soccer Season!

Player Name *

First Name

Last Name

Player Birthdate *

MM

DD

YYYY

Parent/Guardian Name *

First Name

Last Name

Phone

(###)

###

####

NSAA Medical Release *

As parent/legal guardian, I request that in my absence my child/player (minor) be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the minor.

Agree

NSAA Waiver of Liability *

Recognizing the possibility of physical injury associated with soccer and in consideration for the organization or association accepting the registrant for its soccer events, programs and activities (Soccer Programs), I hereby release, discharge and/or otherwise indemnify the association, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the soccer programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Soccer Programs and/or being transported to or from the same, which transportation I hereby authorize. To hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.

Agree