Player Registration Form /
Travel Program August 1, 2015-July 31, 2016
PLAYER’S NAME ______DATE OF BIRTH ______GENDER ______
LAST 4 DIGITS OF SOCIAL SECURITY # ______
ADDRESS ______
CITY ______ST _____ ZIP ______
FATHER/GUARDIAN ______
MOTHER/GUARDIAN ______/ H PH. ______W PH. ______
H PH. ______W PH. ______
Cell Phone (Father) ______
Cell Phone (Mother) ______
E-MAIL ADDRESSES FOR CLUB & TEAM ANNOUNCEMENTS:
Primary ______
Alternate ______
WHEN PARENTS CANNOT BE REACHED, PLEASE CONTACT:
NAME ______NAME ______/ H PH. ______W PH. ______
H PH. ______W PH. ______
OTHER EMERGENCY CONTACT INFORMATION:
______
______/ ALLERGIES AND OTHER MEDICAL CONDITIONS:
______
______
PHYSICIAN ______
INSURANCE CO. ______
POLICY HOLDER ______/ PHONE ______
PHONE ______
POLICY # ______GROUP # ______
UNIFORM INFORMATION:
SHIRT SIZE (Youth S – Adult XL) ______SHORT SIZE (Youth S – Adult XL) ______SHIRT NUMBER (Choice 1) ___ (Choice 2) ___
PARENT/GUARDIAN APPROVAL AND MEDICAL RELEASE
Recognizing the possibility of physical injury associated with soccer and/or the sudden illness at an event, and in consideration for the USSF/USYSA and its affiliates accepting the registrant for its soccer programs and activities (“the Programs”), 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 fields, and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize.
My son or daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer, emergency personnel, and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.
CLUB MEMBERSHIP AGREEMENT
I agree to abide by all team, club, league, state association and national association rules relevant to my participation in the programs and that of my son or daughter. I agree to promptly and fully pay my club fees. My membership shall be effective immediately and shall expire August 1, _2015______.
______Subscribed and sworn to before me this _____ day of ______, 20_____.
SIGNATURE OF PARENT/GUARDIAN DATE
Notary Public ______Seal or original stamp is mandatory