Medical Release Form / Teams | Blue Mountain Indoor Soccer Tournament

Team Information:

Team Name *

Division *

Coach's Name(s): *

Player Information:

Name *

Street Address *

City *

State *

Zip Code *

Emergency Contact: (Parent or Guardian)

Emergency Contact Name *

Emergency Contact Telephone # *

Insurance Coverage (Name, Group #, BIN) *

Recognizing the possibility of physical injury associated with soccer and in consideration of the Eastern PA Youth Soccer Association, The Blue Mountain Soccer Boosters, Tournament Organizers, and The Blue Mountain School District accepting the registrant for this soccer tournament, I hereby release, discharge and/or otherwise indemnify these organizations against any claim by or on behalf of the registrant’s participation in this tournament. I also recognize that any costs that may be incurred as a result of any injury and/or medical treatment are my responsibility and not the responsibility of the above entities. In addition, I authorize any treatment that may be required until such time that I am notified.

By checking this box, I signify that I've read and understand all of the above conditions. *

I agree to all of details specified in this disclaimer.

Signature of Parent/Guardian *

Date *