I hereby give permission for any and all medical attention to be administered to my

 child/children

in the event of accident, injury, sickness, etc. under the direction of John Doyle Soccer until such time as I may be contacted.  I also assume the responsibility for the payment of any such treatment.

Date:

Parent Name (S):

Cell Phone:

Home Phone:

Insurance Company:

Policy Number:

Physician Name and location:

Physician Phone Number:

Please fill in the information above and the print this form out, sign it and mail it to us, or bring to us with your future soccer star. Don't forget to sign it.

Parent Signature:__________________________________________________________