MEDICAL RELEASE FORM

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 the 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 PLAYERS BIRTH_____________ DATE OF LAST TETANUS BOOSTER__________________

KNOWN ALLERGIES OF THIS PLAYER, INCLUDING ANY ALLERGIES TO MEDICINE_________________

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ANY OTHER MEDICAL PROBLEMS, WHICH SHOULD BE NOTED

FAMILY PHYSICIAN____________________________________________________________________

NAME OF PARENT/GUARDIAN___________________________________________________________

ADDRESS_____________________________________________________________________________

CITY/STATE/ZIP_______________________________________________________________________

PHONE_________________ HOME ________________CELL/WORK_______________FAX__________

PERSON RESPONSIBLE FOR CHARGES (if different from above)___________________________________

ADDRESS____________________________________________________________________________

CITY/STATE/ZIP_______________________________________________________________________

PHONE________________HOME___________________CELL/WORK_______________FAX__________

PERSON TO NOTIFY IF PARENT/GUARDIAN IS UNABAILABLE__________________________________

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PHONE_______________HOME____________________CELL/WORK_______________FAX__________

INSURANCE CARRIER___________________________POLICY NUMBER__________________________

SIGNATURE OF PARENT/GUARDIAN_______________________________________________________

STATE OF_______________ COUNTY OF___________________________

Sworn to and subscribed before me on the ____ day of ________________, 20______

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Notary Public in and for the state of Rhode Island Commission expires:

______________________________________ _____________________________

RELEASE TO BE COMPLETED BY PARENT OR GUARDIAN

I am the parent/guardian of ______________________________________, on whose behalf I have submitted the attached application for participation in TOPSOCCER.

I further represent and warrant that to be best of my knowledge and belief, he/she is physically and mentally able to participate in TOPSOCCER. With my approval, a license physician has certified based on an independent medical examination that there is no medical evidence, which would preclude his/her participation. I understand that if he/she has Down Syndrome, a full radiological examination to establish the absence of Atlanto-axial Instability is needed.

In permitting him/her to participate, I am specifically granting my permission, (both during and any time after) to TOPSOCCER to use his/her likeness, name, voice and words on television, radio, film, newspaper, magazines and other media, and in any form for the purpose of advertising or communicating the purposes activities of TOPSOCCER and/or for fund to support this program.

If a medical emergency should arise during his/her participation in TOPSOCCER, at a time when I am not personally present so as to be consulted regarding his/her care, I hereby authorize TOPSOCCER, on my behalf, to take whatever measures are necessary to ensure that he/she is provided with any emergency medical treatment including hospitalization, which TOPSOCCER deems advisable in order to protect his/her health and well being.

I am the parent (guardian) of ______________________________________________; I have read and fully understand the provisions of the above release. Through my signature on this release form, I am agreeing to the above provision on my own behalf and that of my child. I also realize the potential risk involved with my child’s participation in this program. I therefore will not hold the TOPSOCCER program its coaches, volunteers or their agents responsible for harm that comes to my child while he/she is participating in this program.

I hereby give my permission for him/her to participate in TOPSOCCER.

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SIGNATURE OF PARENT OR GUARDIAN DATE