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AYSO Region 418 Chicago Lakefront

Forms

AYSO Participation (Return to Play) Release Form

When a player sustains an injury or a concussion is suspected, the coach will remove the player from further participation in practices or games. The coach will submit an Incident Report to the Regional Safety Director and the player may not participate in further practices or games until the parent/guardian has submitted the AYSO Participation (Return to Play) Release Form. This not only protects AYSO, but more importantly, the participants. Too often injured participants are out playing again before they are physically ready. Players should not participate until they are fit to play again. The form requires a parent or guardian signature in order to help ensure a player is well enough to return to participation.

- A Participation (Return to Play) Release Form must be signed by parent/guardian whenever there is an injury or illness requiring medical treatment including serious illnesses like hepatitis and pneumonia.
- A signed Participation (Return to Play) Release Form is required whenever a player is removed from play for a suspected concussion.

Click on the link below to download the form. Submit the completed form to the Region 418 Safety Director, Luke Perez, at [email protected] The Safety Director will then alert the coach that the player may return to play.

AYSO Participation (Return to Play) Release Form


AYSO Soccer Accident Insurance Claim Form

Soccer Accident Insurance (SAI) – serves as a secondary/excess medical and/or dental insurance should an accidental injury occur during specified AYSO activities and events. If the player or player’s parents are covered by any other health care plan, bills must be submitted to the other plan first. After the primary plan has paid its share of the claim, any remaining balances will be eligible for consideration under the AYSO SAI Plan. It is the responsibility of the claimant to collect the fully completed form from the Regional Safety Director, make a copy for his/her own records and submit the claim form to the address provided on the form within 90 days of the date of injury.

To file a claim, the claimant must:

  1. Download the AYSO Soccer Accident Insurance (SAI) form, below.
  2. The injured person (or their parent/guardian) must complete, sign and date Part A of the claim form and return the form to the Safety Director for signatures. Email the completed claim form to the Region 418 Safety Director, Luke Perez, at [email protected]
  3. The Regional Safety Director and Regional Commissioner must complete, sign and date Part B of the claim form. This section also requires proof of eligibility in the form of the claimant’s AYSO identification number on the printed player registration or volunteer application forms or ID cards.

Soccer Accident Insurance - Overview

Soccer Accident Claim Form

Who is covered:

All AYSO members currently registered (players, coaches, referees and other volunteers) are “Covered Persons” for accidental bodily injury while participating in the following covered activities:

-Team practice sessions, scheduled matches, tournaments, or other sponsored activities (meetings, banquets, fundraisers) provided they are under the direct supervision of an AYSO registered volunteer.
-Group travel, defined as (5) five or more people in one vehicle, directly to and from an AYSO sanctioned event such as practice sessions, matches, tournaments, or sponsored activities, provided that players are traveling as a team and a licensed adult driver operates the vehicle. Group travel which is interrupted for more than two hours, is excluded. (Please see Automotive Liability Chapter for further details)

What is covered?

-Medical/surgical treatment by a doctor or dentist.
-Services of a licensed or graduate nurse.
-Stays in a hospital.
-AYSO Nationally Sanctioned Events

Policy Limits

Soccer Accident Insurance (SAI) pays excess medical costs up to $50,000 maximum per accident to an insured person for accidental bodily injuries incurred as a direct result of participation in a covered activity subject to the policy terms, conditions and exclusions. Eligible expenses incurred within 1 year of the date of a covered accident (one within 1 year of the policy effective date) are eligible for benefits under this policy. Accident Medical and Dental Expense Benefits are only payable for:

-Usual and customary charges incurred after the deductible has been met;
-Those medically necessary covered expenses that the covered person receives;
-Claims when the first medical/dental expense is incurred within 90 days of the covered accident;

All claims must be filed within 90 days of the covered accident and each claim is subject to a $1000 Deductible.

Claimant should consider sending the form Certified/Return Receipt through the US Postal Service.

SAI claims may be submitted before receipt of the Explanation of Benefits (EOB) Form in order to comply with the 90 day filing period, but copies of the EOB and all itemized bills should be submitted as soon as the claimant receives them.

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AYSO Region 418 - Chicago Lakefront

4507 N Ravenswood Ave, Suite 101
Chicago, Illinois 60640

Email Us: [email protected]
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