COMBINED PERMISSION TO TRAVEL AND MEDICAL RELEASE

Player: _________________________________________________ Date: _____________________________
The above named player has been offered the opportunity to travel and play soccer with a Grosse Pointe Soccer Association team (the
“team”). As parent or guardian of the player, I would like the player to have that opportunity. In consideration of the privilege
conferred on the player, I agree, for myself, for any other parent or guardian and for the player, to the following:
1. Purpose: I understand that travel soccer includes travel to and participation in various soccer clinics, try outs,
practices, games, tournaments and other activities sponsored or authorized by the United States Youth Soccer Association, the
Michigan State Youth Soccer Association, the Michigan Youth Soccer League, the Grosse Pointe Soccer Association or the team
(individually and together the “Sponsors”) and that travel includes transportation, accommodations, meals, recreation and various
physical activities. For such purposes the team coaches, team manager and other volunteers may act as chaperones. While those team
volunteers will attempt to provide reasonable supervision of the players, they cannot accept financial responsibility for the health of
safety of the players.
2. Authority: I hereby delegate to the Sponsors and such team volunteers authority to supervise the player during
the player’s participation in travel soccer and to take reasonable disciplinary measures if necessary. I represent that I have advised the
player of the authority hereby conferred.
3. Fitness: I acknowledge that travel soccer is both physical and physically demanding and that good general conditioning
must be the responsibility of the player and the player’s parents or guardians. I represent that the player has recently passed a thorough
examination by a physician and that the player is now fit to participate without limitation in all activities of travel soccer.
Nevertheless, I acknowledge that during travel, clinics, try outs, practices, games and other activities accidents can happen. The
Sponsors and team volunteers cannot be responsible for such accidents. Therefore, I, for myself and for any other parent or guardian,
accept for ourselves and for the player all risk of injury to the player and take full responsibility for any financial consequences arising
out of the player’s participation in travel soccer. I will notify the Grosse Pointe Soccer Association and the team coaches of any
change in the player’s fitness to participate in travel soccer.
4. Medical Release: I hereby delegate to the Sponsors and the team volunteers, and to each of them and their representatives, full
authority in the absence of a parent or guardian to render and secure for the player such emergency medical attention as may be
necessary in their judgment while the player is participating in travel soccer. I, for myself and for any other parent or guardian, hereby
assume responsibility for the costs of any such treatment.
5. Release and Indemnity: I, for myself, for any other parent or guardian and for the player, hereby release the Sponsors and the
team volunteers from any responsibility for the injuries to the player and financial consequences arising out of the player’s
participation in travel soccer, and hereby agree to indemnify and hold the Sponsors and the team volunteers harmless from any loss or
damage related to the player’s participation in travel soccer or to their rendering of securing emergency medical treatment for the
player. I represent that the player is covered by adequate health and other insurance through our own carriers.
6. Relevant Information: While I understand that the team coaches and volunteers are not trained medical personnel, I have
described below certain information which may be relevant to, or in any way restrict the player’s participation in travel soccer (USE
THE REVERSE SIDE IF NECESSARY).

Medical conditions and all medications currently taken:____________________________________________________________
__________________________________________________________________________________________________________
Allergies (and medications): ___________________________________________________________________________________
Other: _____________________________________________________________________________________________________
Insurance Company: ________________________________________________ Physician: ________________________________
Policy Number: ____________________________________________________ Phones: __________________________________
Signed: ___________________________________________________________ Phone: Home: ____________________________
Print: _____________________________________________________________ Work: _____________________________
Parent / Guardian
NOTARY: On this date, before me, the officer named below, appeared _________________________________________________
Known to me or otherwise identified to my satisfaction as the parent / guardian named above: and such parent or guardian affirmed
that he or she had executed the foregoing document for the purposes stated therein.
Date: ____________________________________________ Signed: __________________________________________________
My commission expires: ____________________________ Name: ___________________________________________________