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 AYS0 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:

Mark S. Wagner, MD
2505 Colt Road
Rancho Palos Verdes, CA 90275
(310) 547-9493
mswagner@cox.net


Accepted by AYS0 Regional Safety Director:


___________________________________
Signature

________________________________
Date