ࡱ> rtq7 }bjbjUU 7|7| l"""""""66668nLt6T!:v  $   $" %l i"b  "b b ""!b P"" b  rT"". yl66l$!0T!%%%66"""" YOUTH CLUB REGISTRATION CONFIRMATION Club Name  FORMTEXT      City  FORMTEXT      State  FORMTEXT       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; which will hold this form unless requested by US Club Soccer.] _____________________________ _____________ _____________________________ _____________ Players Signature Date Parent/Guardian Signature Date ______________________________________________________________________________________________ PLAYERS MEDICAL INFORMATION Player s Name  FORMTEXT      Birth Date  FORMTEXT      Street Address  FORMTEXT      City  FORMTEXT      State  FORMTEXT      Zip  FORMTEXT      Email Address  FORMTEXT       Father s Name  FORMTEXT      Home Phone ( FORMTEXT      )  FORMTEXT      Bus Phone ( FORMTEXT      )  FORMTEXT      Mother s Name  FORMTEXT      Home Phone ( FORMTEXT      )  FORMTEXT      Bus Phone ( FORMTEXT      )  FORMTEXT       In an emergency when parent/guardian cannot be reached, please contact the following: Name  FORMTEXT      Home Phone ( FORMTEXT      )  FORMTEXT      Bus Phone ( FORMTEXT      )  FORMTEXT      Name  FORMTEXT      Home Phone ( FORMTEXT      )  FORMTEXT      Bus Phone ( FORMTEXT      )  FORMTEXT       Allergies  FORMTEXT      Other Medical Conditions  FORMTEXT       Physician  FORMTEXT      Home Phone ( FORMTEXT      )  FORMTEXT      Bus Phone ( FORMTEXT      )  FORMTEXT      Medical/Hospital Insurance Company  FORMTEXT      Phone ( FORMTEXT      )  FORMTEXT      Policy Holder s Name  FORMTEXT      Policy Number  FORMTEXT       MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER 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______________________________________ Date ____________________  FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       (Relation to player: father, mother, guardian)     716 8th Ave. North Myrtle Beach, SC 29577 Phone: (843) 429-0006 Email:  HYPERLINK "mailto:admin@usclubsoccer.org" admin@usclubsoccer.org Website: www.usclubsoccer.org Form #R002Youth-3/06 NPfh|~'3EG  *,ܷܷܷyoydjCJOJQJU6CJOJQJ]56CJOJQJ\]>*CJOJQJ CJOJQJ!j5CJOJQJU\!jt5CJOJQJU\&j5CJOJQJU\mHnHu!j5CJOJQJU\j5CJOJQJU\5CJOJQJ\ OJQJ^JOJQJ'NP3jhhhh~$$IflF(#( 06    4 la$If !d8^ V|3  R F x p$$Ifl0(d 064 la$If$a$ ,@BDNPjl    4 6 8 B D P R f h j t v {jCJOJQJUjCJOJQJUj,CJOJQJUjCJOJQJUjDCJOJQJUjCJOJQJU jCJOJQJUmHnHujCJOJQJUj\CJOJQJU CJOJQJ0x z icc$If$$Ifl\<(#(064 la z $If$a$p$$Ifl0(l064 la  & ( < > @ J L R T h j l v x     * , H J ^ ` b l n zjLCJOJQJUjCJOJQJUj`CJOJQJUjCJOJQJUjtCJOJQJUjCJOJQJU jCJOJQJUmHnHujCJOJQJU CJOJQJjCJOJQJU0 .  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