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Newtown Soccer Club, Soccer, Goal, Field




Player Information and Medical Release Form




Player’s Name____________________________________     Date of Birth_____________________


Address __________________________ City ______________ State _____________ Zip Code_________________




Father’s Name____________________ Home Phone ___________________Work Phone_____________________


Mother’s Name___________________ Home Phone_____________________ Work Phone___________________


In an emergency when parents cannot be reached, please contact:


Name ___________________________Home Phone____________________ Work Phone___________________


Name___________________________ Home Phone_____________________ Work Phone___________________




Other medical conditions______________________________________________________


Player’s Physician _______________________________Home Phone ___________________Work Phone______________


Medical and/or Hospital Insurance Company ___________________________Phone____________________


Policy Holder_____________________ Policy # ____________________Group #_________________________



Recognizing the possibility of physical injury associated with soccer and in consideration for the Newtown Soccer Club and its affiliates accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the Newtown Soccer Club, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.




____________________________                                               ___________________   

Signature of Parent or Guardian                                           Date