PARTICIPATION RELEASE FORM

As parent/guardian of:_____________________________________________

I certify that he/she has been released by his/her doctor to full participation without restrictions in the AYSO program as of this date.


Date: ________________ Signature:__________________________________
Specify: ___ Parent or ___ Guardian

Name of Physician: __________________________ Phone: ______________

Address:_________________________________________________________

Signature: ___________________________________ Date: ______________
                               Physician



Please send Completed form to AYSO Regional Safety Director:

Dave Amin, MD, FACEP
Region 10 AYSO Safety Director
36 Harbor Sight Drive Rolling Hills Estates, CA 90274
Phone contact at 310-755-4007 (cell) text or IM preferred


Accepted by AYSO Regional Safety Director:


___________________________________
Signature

________________________________
Date