Youth Sports Medical Release Form
This medical release form must be completed by a parent or guardian for all players participating in youth sports activities. Please provide accurate information to ensure the safety and well-being of your child.
Section 1 – Player Information
Player Full Name
*
Date of Birth
*
/
/
Player's date of birth
Age
Team Name
Jersey Number
Section 2 – Health Information
Known Allergies
Include severity and typical reactions if applicable
Current Medications
Include prescription and over-the-counter medications
Medical Conditions or Disabilities
Include asthma, diabetes, seizures, heart conditions, etc.
Physician Name
Physician Phone
Section 3 – Insurance Information
Insurance Company
*
Policy Number
*
Policy Holder
Section 4 – Parent / Guardian Information
Parent/Guardian Full Name
*
Relationship
Choose One
Mother
Father
Legal Guardian
Other
Primary Phone
*
Email
Emergency Contact Name
Someone other than yourself
Emergency Contact Phone
Section 5 – Authorization and Release
Medical Treatment Authorization
*
A
I authorize league staff and coaches to seek emergency medical treatment for my child if I cannot be reached
Liability Release
*
A
I release the league, its staff, coaches, and volunteers from liability for injuries sustained during participation in league activities
Parent/Guardian Signature
*
Draw
Type
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Date
*
/
/
Date of signature
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