Yadkin Soccer Association
SOCCER RELEASE FORM – 2009 / 20010
Player’s Full Name: ____________________________________ Birthday: ___/____/___
Address: ____________________________________________ Age on Aug. 1:_______
____________________________________________ Phone:_____________
Email Address: _______________________________________ Age Division: U-______
Phone: Home Work Cell
Mother ______________________________ ____________ _________ ___________
Father ______________________________ ____________ _________ ___________
Emergency: __________________________ ____________ _________ ___________
Insurance - is required for all players and is included in the sport fee. This is secondary medical
insurance and takes over payment after your regular insurance has paid, or if you do not have any
insurance. There is a deductible, which you must pay. This insurance is not in force until the sport
fee is paid, so no player may participate in any activity until the sport fee is paid. This is not major
medical coverage; it is limited in its benefits.
Our regular insurance company is _____________________ Policy #:________________
Medical Release - (Authorization for Treatment of a Minor) - We authorize any member of the Yadkin
Soccer Association to give consent to X-ray examination, anesthetic, medical or surgical diagnosis
and treatment by a licensed physician, who is on the staff of a licensed hospital. It is understood that
this Authorization is given in advance of any such specific diagnosis, treatment or hospital care, but is
given to provide authority and power on the part of the Coach to give specific consent to any and all
such diagnosis, treatment or hospital care with the physician in the exercise of his/her best judgment
as may be deemed advisable.
This authorization shall remain in effect until the end of the above designated sport unless sooner
revoked in writing to the Coach.
Liability Release - We understand that these are volunteer organizations and we the parents do
hereby give our approval to our child’s participation in any and all activities. We understand the
nature of the insurance coverage provided, however, we assume all additional responsibility for
hazards incurred in the conduct of activities, transportation to and from activities, and we do further
hereby release, absolve, indemnify, and hold harmless, the Yadkin Soccer Association and those
associated with it (Board Members, Coaches, Officers, Officials, Organizers, Referees, Sponsors,
Assistants, Coaches and Land Owners who have permitted use of their facilities), any and all of them.
In case of injury to our child, we waive all claims against the Yadkin Soccer Association and/or those
associated with it.
We agree to abide by the rules and By-Laws of the Yadkin Soccer Association and also agree to take
no legal action against either organization or those associated with it concerning any rule.
I certify that I have read, understand and agree to the items listed above. (This form MUST be signed
by a parent or legal guardian).
Signed: _________________________________________ Date __________
Parent or Legal Guardian Signature