Ballard Youth Soccer Club
1752 NW Market St. # 224
Seattle, WA 98107

AUTHORIZATION TO PLAY, MEDICAL RELEASE, AND WAIVER FORM
With the signature(s) below, permission is hereby granted for ___________________________ ________________________ (participant) to participate in all practice sessions, games and other activities involving Ballard Youth Soccer Club during the _______________season. This permission extends to any travel to and from any and all practice sessions, games and other activities sponsored and arranged by the Soccer Club.
This permission is granted without reservation. Recognizing the risks presented by thecompetitive contact sport of soccer, the signature below indicates a knowing, voluntary release of any claim which might be asserted against Soccer Club, its officers, administrative assistants, coaches,assistant coaches, managers, sponsors, chaperones, designated drivers, volunteers, and any other agents representing Soccer Club, or SYSA and its officers or agents or representatives, the local league organization of which Soccer Club is a member. By waiving any right to assert a claim, I am agreeing to release, absolve, indemnify and hold harmless any and all parties previously mentioned for any and all liability arising from any injuries incurred by participant in Club. My waiver expressly means that I, participant’s legal parent or legal guardian, accept and assume all risks and hazards inherent in and related to the activities of Soccer Club, including any travel to and from any activities sponsored and arranged by Soccer Club.
This permission also includes my authorization for emergency medical treatment deemed appropriate and necessary by any coach, assistant coach or representative or agent thereof for participant, including transport to the nearest medical facility adequate to treat the emergency. Participant has the following medical condition (s):

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Mother’s name ________________________

Home Phone ____-______ Work/Cell Phone ____-______

Father’s name _________________________

Home Phone ____-______ Work/Cell Phone ____-______

Physician _________________________________________________

Phone _______-______________
Health Insurance Plan _______________________________________________________________
Medical Plan Number ________________________________________________________________

I have read this authorization to play, medical release and waiver, acknowledge that I understand it and agree to be bound by it.

Dated ___________________ Parent/Guardian Signature ___________________________________
Dated ___________________ Parent/Guardian Signature ___________________________________