Medical Authorization & Liability Waiver

Created by Todd Higgs
Jul 15

Emergency Medical Authorization
I certify the above information is correct and complete, and know of no medical or other reason why the player cannot participate in Portageville Youth Soccer ("PYS") activities. As parent/legal guardian of this player, I give my consent for emergency medical and/or dental care in the event of any injury or illness while involved in a PYS program, and accept responsibility for prompt payment of such care and services. It is understood that effort shall be made to contact me prior to rendering treatment to my child, but that any of the above treatments will not be withheld if I cannot be reached.

Waiver & Release of Liability
I agree that the information provided above is true & accurate, and that I have the authority to register the player listed in the youth soccer program sponsored by the Portageville Park Board. I fully understand that the participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and assume all the foregoing risks and accept responsibility for the damages following such injury as may occur from participation in this program. I agree to abide by the rules and policies set forth by PYS, and to repair or replace any equipment damaged as a result of intentional misuse. I agree to indemnify and hold harmless PYS, Portageville Park Board, the City of Portageville, and their representatives or employees from any and all claims of injury to person or property that result from participation in this activity.

I have read and fully understand the above Emergency Medical Authorization and Waiver/Release of Liability, and sign voluntarily.

Portageville Youth Soccer
Recreational youth soccer for pre-K through 6th grade in Portageville, MO and surrounding area.