US Club Soccer Medical Waiver 24-25

US Club Soccer Medical Waiver
YOUTH PLAYER REGISTRATION FORM
League Name
NISL or NPL
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.]
Player's Signature*

Clear
Today's Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Today's Date

MonthDayYear
Date
PLAYER'S MEDICAL INFORMATION
Player's Full Name*
Player's Birth Date*

MonthDayYear
Date
Player's Gender*

FemaleMale
Player's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Email*
example@example.com
Parent 1 Name*
Parent 1 Phone*
Parent 1 Email*
example@example.com
Parent 2 Name
Parent 2 Phone
Parent 2 Email Address
example@example.com
In an emergency when parent/guardian cannot be reached, please contact the following:
Emergency Contact 1 Name*
Emergency Contact 1 Phone Number*
Please enter a valid phone number.
Emergency Contact 2 Name
Emergency Contact 2 Phone Number
Please enter a valid phone number.
Please list player allergies
Please list other medical conditions
Physician*
Physician Phone*
Medical/Hospital Insurance Company*
Insurance Co Phone Number*
Please enter a valid phone number.
Policy Holder's Name*
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/participan 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.
Parent Signature*

Clear
Today's Date*

MonthDayYear
Date
Relation to player*

FatherMotherGuardian
Team Name*
Should be Empty:

US Club Soccer Medical Waiver

YOUTH PLAYER REGISTRATION FORM

PLAYER'S MEDICAL INFORMATION

MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER