FC America
Voluntary Medical Release

Players Name:___________________________________________________ Birth Date:___________________  In consideration of my child's participating in soccer training and other team related activities, and for other good and valuable consideration received by me. I, _________________________________________________ the parent or guardian the minor child named above having actual knowledge and conscious appreciation of the particular dangers involved, do voluntarily consent to my child's participation in the aforementioned activities and release F.C. America, it's board members and coaching staff from liability therefrom and assume the risks arising therefrom.

I hereby warrant to F.C. America that my child has no chronic diseases, including but not limited to, asthma epilepsy, heart conditions, congenital defects, bone or diseases of the blood and including HIV, except:_______________________________
Current medications:_________________________________________________
Medical alert for:____________________________________________________
Date of last tetanus:___________________

Being fully aware of the hazards and possible consequences involved in treatment of the above described routine and major emergency conditions, I being legally competent to give consent, hereby consent to such treatment. Regarding routine first- aid, major emergencies, or medical trauma, I understand that the staff would provide whatever care or treatment they reasonably could and would refer to the appropriate physician/facility for further treatment of such. I hereby authorize consent to x-ray, examine, anesthetic, medical or surgical diagnosis or treatment, or hospital care, which is deemed needed and rendered under the guidance or special supervision of the physician.

All medical expenses incurred due to my child's participation in the above named organization and activities are understood to be my responsibility and hereby give authorization to provide such necessary insurance information to be used, should my child incur an injury or illness that requires medical attention. I further understand that the medical insurance coverage afforded under Florida Youth Soccer Association master policy is secondary coverage to my personal health coverage if in force at time of treatment.

I further understand that involvement in F .C. America and team related activities require travel to tournaments, training sessions, and soccer related activities but not limited to athletic and social events. I hereby authorize the officers, coaching staff, leader, or agent (s) of the team, club or state association to transport as required to any and all events.

I do hereby declare and represent that in making, executing and tendering this statement of voluntary medical release and travel consent. I understand and acknowledge the circumstances involved in my child's participation in the described activities and that I have read this statement, understood it contents, and executed it of my free will and choice, and do so in the best interest of my child.
_____________________________________________ Executed this _________Day of ___________ 20____
Parent Signature

Address:_____________________________________________ City:_________________________ St:______

Home Phone: __________________  Work Phone:___________________  Cell Phone:___________________

Insurance Carrier:___________________________________ Policy Number: ___________________________

Sworn to and subscribed before me on this ________ Day of ___________________ 20_____

__________________________________________  My Commission Expires:______________________
Notary Signature
Affix Seal Below