Tualatin Valley Youth Football
MEDICAL RELEASE

I hereby release ___________________________________ to play TACKLE FOOTBALL for the Fall football season.
                                          (Print Player's Name)

List any Allergies or Other Medical Condition: ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Doctor/Nurse Practitioner Name (please print) _______________________________________________________
Doctor/Nurse Practitioner SIGNATURE _____________________________________________________________
Doctor/Nurse Practitioner Phone __________________________________________________________________

*NOTE: This form needs to be physically signed by a Doctor or Nurse Practitioner!! A stamped signature will NOT be
accepted. This form must be turned into the appropriate football league BEFORE player can receive any equipment and
participate in practice. A fax or copy of the original will be accepted.

Date _____________________(This form must be signed after February 1st)

I understand all of the above information to be accurate. I, as parent/guardian of said player/minor hereby give permission for said minor to participate in any and all activities sponsored by Tualatin Valley Youth Football.

Parent/Guardian (Please Print)_______________________________________________________________
Parent/Guardian Signature _________________________________________________________________
Date _____________________