Med-Reg. Form
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Proof of Birth
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Complete from online information
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Team #
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7
8
9
Phone: (843) 429-0006
10
11
Website:
www.usclubsoccer.org
Email: admin@usclubsoccer.org
I hereby consent to the above-named club
registering me with US Club Soccer. I
understand that I may be registered to only one US Club Soccer member club at
any time. [Note: it will not be necessary to complete
this form again as long as the player is with this club.]
x_____________________________ _____________ x_______________________________ _____________
Player’s Signature Date
Parent/Guardian Signature Date
Player’s Name___________________________________________ Birth Date ____________________ Age __________ Street Address__________________________________ Apt. ______ City_________________________ Zip___________
Father’s Name_______________________ Home Phone
(_____)______________ Work Phone (_____)_______________
Mother’s Name______________________ Home Phone
(_____)______________ Work Phone (_____)_______________
In an emergency when parent/guardian cannot be
reached, please contact the following:
Name_____________________________ Home Phone
(____)________________ Work or Cell Phone (___)__________
Name_____________________________ Home Phone
(____)________________ Work or Cell Phone (___)__________
Allergies
(write “none” if none)
_______________________________________________________________________
Other
Medical
Conditions_____________________________________________________________________________
Physician__________________________ Home Phone (____)_________________ Work Phone (_____)_____________
Medical/Hospital Insurance
Company_______________________________ Phone (____)_________________________
Policy Holder’s
Name_____________________________________ Policy
Number______________________________
I hereby give my
consent to have an athletic trainer, coach, team manager, emergency medical
technician, nurse, medical treatment facility, and/or doctor of medicine or
dentistry or associated personnel provide the applicant/participant with
medical assistance and/or treatment and agree to be financially responsible for
the cost of such assistance and/or treatment.
I understand treatment for injury will be based on information provided
herein. I hereby authorize emergency
transportation of the applicant/participant to a medical treatment facility
should an individual listed above consider it to be warranted.
I recognize the
possibility of physical injury associated with soccer, and hereby release,
discharge, and otherwise indemnify the club, US Club Soccer, their sponsors,
the USSF and its affiliated organizations, and the employees and associated
personnel of these organizations, against any claim by or on behalf of the
soccer player named above as a result of that player’s participation in US Club
Soccer programs and/or being transported to or from the same, which transportation
I hereby authorize.
Signature x
__________________________ Date_________ Relation to player:
father, mother, guardian ____________