PLAYERS
NAME_______________________________________________________________
ADDRESS_____________________________________________________________________
PHONE_______________________________________________________________________
DATE
OF BIRTH________________ HEIGHT_______________ WEIGHT________________
______________________________________________________________________________
* NOTE TO PHYSICIAN: If this child has Down Syndrome, TOPSOCCER requires that he/she
have a full radiological examination establishing
the absence of Atlanto-axial Instability before
they may play the sport of soccer.
______________________________________________________________________________
I have reviewed the above player’s health information and examined the player, and certify there is
no medical evidence to me, which would preclude him/her from participation in the TOPSOCCER program.
PHYSICIAN’S
NAME___________________________________________________________
ADDRESS_____________________________________________________________________
CITY___________________________ STATE______________
ZIP______________________
PHYSICIAN’S
SIGNATURE______________________________________________________
PHYSICIAN’S COMMENTS______________________________________________________
______________________________________________________________________________