Fillable YOUTH PLAYER REGISTRATION FORM

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YOUTH PLAYER REGISTRATION FORM

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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.]
This form must be retained by the club for at least ve (5) years or until the player’
s 18
th
birthday, whichever occurs last.
Player’s Name: Birth Date: Gender:
Street Address: City:
State: Zip: Email Address:
Parent Name: Home Phone: Bus Phone:
Email Address: Cell Phone: Receive Texts?
Parent Name: Home Phone: Bus Phone:
Email Address: Cell Phone: Receive Texts?
In an emergency when parent/guardian cannot be reached, please contact the following:
Name: Phone 1: Phone 2:
Name: Phone 1: Phone 2:
Please list player allergies:
Please list other medical conditions:
Physician: Phone 1: Phone 2:
Medical/Hospital Insurance Company: Phone:
Policy Holder’s Name: Policy #:
Player’s Signature Date Parent/Guardian Signature Date
Club Name: City: State:
League Name:
YOUTH PLAYER REGISTRATION FORM
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
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stand 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
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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.
MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER
PLAYER’S MEDICAL INFORMATION
Signature: Date: Relation to player:
Form #R002-Y – 5/2012
/s/
/s/
/s/
PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM
First Name: Last: Date of Birth: Gender:
Address: City: State: Zip:
EMERGENCY INFORMATION
Father’s First Name: Last: Home Ph #:
Mother’s First Name: Last: Home Ph #:
In an emergency, when parents cannot be reached, please contact:
First Name: Last Home Ph #:
First Name: Last Home Ph #:
Allergies:
Other Medical Conditions:
Physician First Name: Last: Home Ph #:
Work Ph #:
Medical and/or Hospital Insurance Co.: Ofce Ph #:
Policy Holder: Policy #: Group #:
PLEASE COPY BOTH SIDES OF YOUR HEALTH INSURANCE CARD AND ATTACH TO THIS
FORM PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE
Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting
my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent
to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, its
member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of elds and facilities
utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s participation
in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from
the Programs.
My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of
participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached
hereto, setting forth any specic issue, condition, or ailment, in addition to what is specied above, that my child has or that may impact
my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide
my son/daughter with medical assistance and/or treatment and agree to be nancially responsible for the reasonable cost of any such
assistance and/or treatment.
Signature of Parent/Guardian Date
/s/
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YOUTH PLAYER REGISTRATION FORM

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Completed 25 March 2022

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