Emergency Medical Release & Liability Waiver
Participant must complete and submit this Illinois Youth Soccer Association (IYSA) Emergency Medical Release & Liability
Waiver before participating in IYSA and/or IYSA Member Programs/Events.
Participant’s Name _________________________________________________________ Gender________________ Birthdate________________
Street Address (Not PO Box) ___________________________________________City __________________________________ Zip_____________
Primary Phone ___________________________ Email___________________________________________________________________________
For a minor participant, enter parent/guardian’s phone and email:
Parent/Guardian Name________________________________________ Primary Phone (_____)____________ Other Phone (_____)_____________
Parent/Guardian Name________________________________________ Primary Phone (_____)____________ Other Phone (_____)_____________
Emergency Contacts for Participant:
Print Name________________________________________________________________________________ Primary Phone (_____)____________
Relationship to Participant ___________________________________ Email___________________________________________________________
Print Name________________________________________________________________________________ Primary Phone (_____)____________
Relationship to Participant ___________________________________ Email___________________________________________________________
Allergies _________________________________________________________________________________________________________________
Other Medical Conditions/Concerns____________________________________________________________________________________________
Physician____________________________________________________ Primary Phone (_____)____________ Bus Phone (_____)_____________
Medical/Hospital Insurance Company_____________________________________________________________ Phone (_____)________________
Policy Holder's Name___________________________________________________________ Policy Number________________________________
On behalf of myself and the above listed participant if the participant is a minor, I/We the undersigned acknowledge and fully understand that the participant will
be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not
only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any
equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal
responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue Illinois Youth
Soccer Association, its directors, officers, employees, coaches, managers, agents, sponsors and associated personnel including those of its affiliated
organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as “releasees”, from any and all liability
to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the participant resulting from his/her participation in the
Programs and/or being transported to or from the same, which participation and transportation, after careful consideration I/We hereby authorize. I/We certify that
the participant has received a physical examination by a physician and has been found physically capable of participating in the Programs. I/We hereby give
my/our consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the participant with medical assistance
and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I/We agree to save and hold harmless and indemnify
each and all parties herein referred to as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be
imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of
the releasees. I/We hereby consent to any and all uses and displays by the releasees of the participants name, voice, likeness, image, appearance and
biographical information in, on or in connection with any pictures, photographs, audio and video recordings, digital images, all of which are hereinafter referred to
as depictions”, that are shown on websites, in television programs and advertising, sales and marketing brochures, books, magazines, all other printed and
electronic forms and media including without limitation for the purpose of promoting Illinois Youth Soccer Association and/or its initiatives and the sport of soccer
and for promotional, commercial other purposes as determined by Illinois Youth Soccer Association anywhere in the world in its sole discretion. On behalf of the
participant, I/We understand that all depictions shall be the sole property of the Illinois Youth Soccer Association and neither I/We nor the participant shall receive
any compensation in connection with their use. Further I/We hereby release, waive and discharge any claims of any kind or nature arising out of or relating to the
use of the depictions against the Illinois Youth Soccer Association and its releasees. On behalf of the participant I/We have read the above waiver/release and
understand that I/We have given up substantial rights by signing this release and sign below voluntarily. I/We understand that this document may not be altered
in any manner and that any alteration without the express written consent from the Illinois Youth Soccer Association will cause the participant to be removed from
the Program. (Updated 2/10/2020)
Parent/Guardians’ Signatures are required if participant is under the age of 18. Signature is required from Participant aged 18 or older.
Parent/Guardian’s Signature (Print & Sign)__________________________________________________________________ Date________________
Parent/Guardian’s Signature (Print & Sign)__________________________________________________________________ Date________________
Participant’s Signature (Print & Sign)_______________________________________________________________________ Date________________