ࡱ> @B?@ bjbjצצ ""0 Ph h h 8  <$, #######$h%R'F#@# #   jl  # #  n!d,# @|dv=h 6^" g#T $0<$" ( (@#(#HhMJ <##h jh  Players Name: _______________________________________ Date of Birth: ____________________ Social Security #: ___________________________ Address: __________________________________________________ City: _________________________________ State: ___________ Zip: _______________ EMERGENCY INFORMATION Fathers Name: ___________________________ Home Phone: ______________________ Work Phone: _____________________Cell: _______________ Mothers Name: __________________________ Home Phone: ______________________ Work Phone: _____________________Cell: _______________ In an emergency, when parents cannot be reached, please contact: Name: ___________________________ Home Phone: ______________________ Work Phone: _____________________Cell: _________________________ List known allergies: ____________________________________________________________________________________________________________________ Other medical conditions: ______________________________________________________________________________________________________________ Doctor to notify in emergency: ________________________________________________________ Phone: ________________________________________ PLEASE PHOTOCOPY BOTH SIDES OF YOUR MEDICAL INSURANCE CARD AND ATTACH TO THIS FORM OR IN LIEU OF PHOTOCOPYING YOUR MEDICAL CARD, YOU MAY INSTEAD FILL OUT THE FOLLOWING: Name of primary Medical and/or Hospital Insurance Company: _______________________________________ Phone: _______________________ Name of policyholder (will usually be father or mother): ______________________________________________________________________________ Policy #: ______________________________________________________________ Group ID #: _____________________________________________________ PARENTS APPROVAL AND MEDICAL RELEASE Recognizing the possibility of physical injury associated with soccer and in consideration for the Harrison Youth Soccer Club, Inc. (HYSC) accepting the Player to participate its programs and activities (the Programs), I hereby release, discharge and/or otherwise indemnify HYSC and its officers, directors, trustees, leaders, volunteers, coaches, trainers, agents, sponsors, employees and all associated personnel as well as the owners of fields and facilities utilized for the Programs against any claim made by or on behalf of the Player and/or the Players parents, guardians and other relatives arising as a result of the Players participation in the Programs and/or being transported to or from the Programs, which transportation I hereby authorize. The Player has received a physical examination by a licensed physician and has been found physically capable of participating in the Programs. I hereby give my consent to have the individuals in charge of the Programs, including any coach, assistant coach or trainer affiliated with HYSC act as my surrogate in securing ambulance service and to have an athletic trainer and/or doctor of medicine or dentistry provide the Player with medical assistance and/or treatment under whatever conditions are necessary to preserve the life, limb or well-being of the Player, and I agree to be responsible financially for the cost of each assistance and/or treatment rendered. 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