Tournament Name:_____________________________________________________

MEDICAL/LIABILITY RELEASE
I am the parent and/or the legal guardian of _______________________________ who is participating in the Tournament listed above sponsored by the Soccer Association of Columbia – Howard County, in the State of Maryland. I hereby enroll my child to participate in any and all activities associated with this Tournament, and I waive all claims against the coaches, organizers, sponsors, supervisors, coordinators, counselors, related personnel, and employees which might arise as a result of injuries in approved team activities.

I confirm that my child is covered by a medical insurance policy - policy name and number provided by our family or otherwise - and I have made all arrangements to determine his/her physical fitness to participate on this team or in its related activities. I hereby give consent for my child to be medically and/or surgically treated for injuries.
Insurance

Carrier:_________________________________________________________

Policy Number:__________________________________________________
Physician's Name: _______________________________________________
Physician's Phone:_______________________________________________
Known Allergies:_________________________________________________
Medication:______________________________________________________

Signature of Parent/Legal Guardian _________________________________

Date:______________

Parent Contact Phone:_________________________________________________________

Other Emergency Contact:________________________________________________________