Please print this out and fill it in. Sign and enclose with payment of dues.
Email neighborhoodsoccerleague@gmail.com with any questions. Thank you!
NEIGHBORHOOD SOCCER LEAGUE
As the parent/legal guardian of______________________________________, I request that in my absence the above-named player 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 above 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 above-named player.
Date of Player’s Birth ____/_____/_____
Month Day Year
Known allergies of this player, including any allergies to medicine:
Any other medical problems that should be noted:
Family Physician / Phone Number:
Name of Parent/Guardian:
Phone: Home: Work: Cell:
Person responsible for charges (if different from above)
Phone: Home: Work: Cell:
Person to notify if parent/guardian is unavailable:
Phone: Home: Work: Cell:
Insurance Carrier / Policy Number:
Signature of Parent/Guardian:
