NEWTON GIRLS SOCCER

COLUMBUS DAY INVITATIONAL TOURNAMENT

OCTOBER 6 & 7, 2007

GENERAL RELEASE

This form must be in the possession of the team’s coach or representative

 at all times throughout the tournament weekend.

In registering my child as a participant in the Newton Girls Soccer Columbus Day Invitational Tournament, I understand that my child and I assume any and all risks which might be associated with this activity, and waive and release all rights and claims which my child, heirs, executors, administrators, assigns or I may have against the Newton Girls Soccer, its directors, coaches, officials, or representatives for any and all injuries or damages of any kind suffered as a result of participation in the NGS Columbus Day Invitational Tournament.

Þ Signature of parent/guardian:  _______________________________________________________________

Team (Town/Age Group):  _____________________________________ Date:_____________________________

MEDICAL RELEASE FORM

As the parent/legal guardian of _______________________________________, I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment.  I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor.  I have not been given a guarantee as to the results of examination or treatment.  I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of player’s birth_____/_____/_____                   Date of last Tetanus Booster_____/_____/_____

                             Month    Day     Year                                                                 Month   Day   Year

Known allergies of this player, including any allergies to medicine________________________________________

____________________________________________________________________________________________

Any other medical problems which should be noted ___________________________________________________

____________________________________________________________________________________________

Family Physician_________________________________________  Phone  (_____)________-________________

Name of Parent/Guardian________________________________________________________________________

Address______________________________________________________________________________________

City/State/Zip _________________________________________________________________________________

Phone_____________________________

Insurance Carrier_________________________________________  Policy Number_________________________

Þ Signature of Parent/Guardian____________________________________________________________________

U.S. YOUTH SOCCER ASSN

      FORM P15 - 2/15/95