ࡱ> ;=:Y U bjbjWW &,==H ]8P \dv ; = = = = = = $,  ha a ; ; 6; ; 1 <; New Jersey Youth Soccer Medical Release Form Players NameDate of BirthGender M FAddressTownStateZip Code Contact Information Fathers NameHome PhoneWork PhoneMothers NameHome PhoneWork Phone In an emergency when parents cannot be reached, please contact: NameHome PhoneWork Phone Medical Information Allergies Other medical conditions Players Physician Phone Primary Medical Insurance Company Policy HolderPolicy #Group # PARENTS APPROVAL AND MEDICAL RELEASE Recognizing the possibility of physical injury associated with soccer and in consideration for New Jersey Youth Soccer accepting the registrant for its soccer programs and activities (the Programs), I hereby release, discharge and/or otherwise indemnify the New Jersey Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrants participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the cost of each assistance and/or treatment. Signature of Parent or GuardianDate Subscribed and sworn to me this ______________day of __________________, 20________ Signature ____________________________________ My commission expires: _______________________________________ Notary Public 9/25/2007 /2XZac578Xlwz*5 [ : H R T U CJOJQJCJ55CJ>*CJCJ5CJOJQJ 5OJQJOJQJ jU#/012@AOPWd$$$$ $$l0f* $$$$ /012@AOPWXZacdefghijklmnvw|}78=>IJUVWXlmwxyz             Rdefghijklm$$$$[$$l ֈ!D%*Rd! mnvw|}$$$q$$l ִe t"&*h}h36 {{$$$ X t"q$$l ִe t"&*h}h36 $$$[$$l ֈH4<p#*  4,78=>IJUV$$$ X t"[$$l ֈH4<p#*  4, VWXlmwxyzf/$$l 0*'$ X t"[$$l ֈH4<p#*<x4, i[$$l ֈT4P<|)* 4,$$$/$$l 0p*," )*0 1 2 3 4 5 U V [ \ ] ^ # H K L R S T U V )G$$l 4\\ X p#*0,$$$ )*0 1 2 3 4 $$$$[$$l ֈ4p#*Xp, 4 5 U V [ \ ] ^ # H R S T Ŝ~~$$:$$l4FHl p$$:$$l4FHl pT U $$1hP/ =!"#8$%DdnlrT  c AC:\Documents and Settings\Al\My Documents\My Webs\NJYS\images\logo.gifbfkj.DqHfBDn: %BUdkj.DqHfPNG  IHDRnlMwPLTETN&.1sfdopjdc?:GVPA ́?GHsdn5FO[͘NihDPPY]lwQOCQƑ(䈂$ddΧ44X;;rnra]o?`[@"姧ݴ]]Yww[c8FT'ih3rtׄ(GH}guT1LXZ'\[dKHLsq{v0I\OPjsΟxI\ȀLA'alhA(vuFGLͮ??ba*blLQJ)ts$1XZ_^Ul;=ZL]\L4NOpĞLzyok<?A{Q.JWxXV(,+`4q|ܝ|!rm!9̀@P/Ҳ3'Mm$I)}iPѨ_lC*x@ok=K:27twBX|VA6nҁ]Y3q)DtF\?HnnT!GjQ;uGݸN\t0Av[(}zE<&>U7VΑG%I:emZWʘc80<<,/bKuͅ YWk{2CSG (cT2=0-m*W-Ip ׶AX"CF͗? 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