PLAYER'S MEDICAL INFORMATION

Player Medical Information

University City Futbol Club 2024-2025
Players Full Name*

First NameLast Name
Birth Date*

MonthDayYear
Date
Gender:*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
example@example.com
Parent Name:*

First NameLast Name
Parent Phone Number*
Please enter a valid phone number.
Parents Phone*
Receive Texts (Yes/No)*
Email Address*
example@example.com
Parent Name:

First NameLast Name
Parent Phone Number
Please enter a valid phone number.
Phone
Receive Texts (Yes/No)
Email Address
example@example.com
In an emergency when parent/guardian cannot be reached, please contact the following:
Name*
Name*
Please list player allergies*
Please list other medical conditions*
Physician*
Policy Holders Name*
Medical Hospital Insurance Company*
Policy Number*
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, University City Futbol Club, 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 University City Futbol Club programs and/or being transported to or from the same, which transportation I hereby authorize.

Privacy Policy & Terms of Use: I acknowledge and agree that I have read, understand and agree to University City Futbol Club's Privacy Policy & Terms of Use (collectively, the “Policy”), available at usclubsoccer.org. The Policy describes University City Futbol Club practices for collecting, maintaining, protecting and disclosing player information. Pictures and videos taken during practices and games may be used for social media and marketing. In signing below, you agree on your own behalf or on behalf of your child or guardian, as applicable, to the provisions of the Policy and any successor Policy then-in-effect.
Signature*

Clear
Today's Date*

MonthDayYear
Date
Relationship to Player*
Should be Empty:

Player Medical Information