WISCONSIN YOUTH SOCCER ASSOCIATION EVENT MEDICAL RELEASE FORM 2025-2026 SEASON 

Participant’s Name: 

Date of Birth (MM/DD/YY): 

Gender: M F Club: 

Emergency Contact: 

Emergency Phone: 

Doctor: 

Doctor Phone: 

Medical Conditions: 

Allergies: 

IMPORTANT MEDICAL AND LIABILITY RELEASE – MUST BE SIGNED Recognizing the possibility of injury or illness, and in consideration for the Wisconsin Youth Soccer Association (WYSA), US Youth Soccer and members of US Youth Soccer accepting me as a player in the soccer programs and activities of WYSA, US Youth Soccer and its members (the “Programs”), I consent to my participation in the Programs. Further, I release, discharge, and otherwise indemnify WYSA, US Youth Soccer, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of myself as a result of my participation in the Programs and/or being transported to or from the Programs, which transportation I authorize. I have received a physical examination by a physician and has been found physically capable of participating in the Programs. I give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide me with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment. I agree that if it appears that I may have sustained a concussion or head injury that I am to be removed from the competition until such time that a trained medical professional can examine me and approve my return to play soccer. In such case, I understand that I am to provide a written clearance for my return to play soccer. . 

Signature: 

Date: