South County Youth Soccer

Contact Information:
730 Kingstown Rd, Box #11
Wakefield, RI, 02879
Phone: 401-782-8200 FAX: 782-8203

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Medical/Release Waiver


After you register your child and you see the Certificate of Registration page come up, you should scroll down and you will see that the Medical Release/Waiver is all filled out with the information you gave when you filled out the registration form. If you clicked out before scrolling down, then this is the form you need to fill out and give to your child/children's coach. Every coach needs to have this with him or her at all times in the event of an emergency.


PLAYER'S NAME:____________________________________

PLAYER'S ADDRESS:_________________________________


DATE OF BIRTH:____________________________________

HOME PHONE: ____________________________________

PARENT #1__________________________ Phone: ____________________

PARENT #2__________________________ Phone: ____________________

Medical Conditions: ____________________________

Known Allergies: ______________________________

Medical Insurance: _____________________________

Policy Holder: ____________________ Policy Number: _________________

Group Number: ____________________

Player's Doctor: __________________ Phone Number: ___________________

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

Name: ________________________________ Phone: ___________________

Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/USYSA and its affiliates accepting the registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, 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 participation 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 Guardian Date

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