MEMBERSHIP AND MEDICAL RELEASE FORM

Program Year: 2017

Program: Travel ______House______

P.O. Box 94 Akron, New York 14001

Player Information / Last Name / First Name / MI / Birthdate
Address / City / State / Zip
Home Phone / Cell Phone / Gender
Male ______Female ______
Email / Last Soccer Club/Team / # of Seasons Played
Player Medical Information / Insurance Carrier / Policy #
List Any Medical Problems
Emergency Contact / Relationship / Phone
Doctor's Name / Phone
Parent(s)/Guardian Information / Parent/Guardian #1 / Phone / Cell Phone
Address / City, State, Zip / Relationship
Parent/Guardian #2 / Phone / Cell Phone
Address / City, State, Zip / Relationship
Legal Authorization / As the parent/legal guardian of the above named player, I request that in my absence the above named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I accept full financial responsibility for any such treatment. I also give permission for any transportation required to a medical facility and assume full financial responsibility for said transportation. Recognizing the possibility of injury associated with soccer and in consideration for the USSF/USYSA and its affiliates accepting the registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify the USSF/USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs/Tournaments against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs/Tournaments and/or being transported to or from same, which transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs/Tournaments.
I have read the information above and fully understand and accept responsibility as it is outlined.
Signature of Parent/Legal Guardian / Date
Official Use Only
Registration/Transfer/Change / Birthdate Verified / Player Fee / Other Fee / Cash/Check
Picture Received / Received by / Uniform Fee / Total Fees / Date

MEMBERSHIP AND MEDICAL RELEASE FORM

Program Year: 2017

Program: Travel ______House______

Official Use Only
Registration/Transfer/Change / Birthdate Verified / Player Fee / Other Fee / Cash/Check
Picture Received / Received by / Uniform Fee / Total Fees / Date
Uniform / Youth / Adult / Volunteer/Parental Support
XS / S / M / L / XL / XS / S / M / L / XL / Coach / Concessions / Reporter
Shirt / Asst. Coach / Field Preparation / Newsletter
Shorts / Team Manager / Clerical / Special Projects
Socks / Team Parent / Publicity / Donor
Jersey Number / Referee / Fundraising / Other
CHOICE / 1st / 2nd / 3rd / 4th / Tournament / Board Member

FORM 1001 (1/13)

Akron Soccer League, Inc.

Soccer Player/Parent Code of Conduct

Soccer is a competitive, contact sport and winning is an aspect of the game. It is far more important to promote: FAIR PLAY and FUN while developing the basic skills and knowledge of the game. The ultimate goal of the league is to have all players, parents, coaches and spectators keep this in the forefront of their minds as they participate in the game.

The REFEREE is the official on the field and as such can and will penalize players on or off the field of play for breaches of the rules of the game. This includes fouls against other players and dissent, disrespect, or abuse of the referee. Obscene language and profanity will not be allowed. The referee may also warn, caution or eject (with or without previous warning) a player, coach, parent or spectator. The referee has that authority before, during and after the game. The use of tobacco and alcohol at games and practices is strictly prohibited.

AS A SOCCER PLAYER, I promise to follow all the rules of the game, come to practices and games prepared, abide by the referee’s decisions, and demonstrate good sportsmanship both on and off the field.

AS A SOCCER PARENT/SPECTATOR, I promise to enthusiastically support the players, to avoid coaching from the sidelines, avoid negative criticism toward the coaches, other players, other parents and referees.

I, the undersigned parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the USYSA (United States Youth Soccer Association) and its affiliated organizations and sponsors.

______

Player Name

______

Parent/Guardian Signature Date

Minor Photo Release Form

I give Akron Soccer League permission to publish in print, electronic, or video format the likeness or image of my child. I release all claims against the League with respect to copyright ownership and publication including any claim for compensation related to use of the materials.

MINOR’S NAME: .

YOUR NAME .

(Parent or Guardian, Please print)

YOUR SIGNATURE: DATE: .

General Guidelines: It is recommended that a release be obtained when photographing or videotaping a minor (under 18).

Parent or guardian signatures are required; signatures of minors are not sufficient. When images are published, ASL will take cautionary steps to provide minimum identifying information and will not use specific street or mailing addresses, e-mail addresses, or phone numbers.