Kickin' It Social Registration

Kickin' it Social at Mt Barker United Soccer Club is the ultimate social soccer program for anyone aged 15 and over! Perfect for beginners, those looking to get active, or anyone who simply wants to have a kick in a relaxed, non competitive and friendly environment. Played on a smaller pitch, it’s all about having fun, meeting new people, and improving your soccer skills without any pressure. Bring your friends or join solo and make new connections – no prior experience needed. Get ready to enjoy a fun, inclusive soccer experience for all fitness and skill levels!

$10 Per Session payable on entry, no pay no play. *Card payments preferred

Player's Name

First NameLast Name

Phone Number

Email

example@example.com

Birth Date

DayMonthYear

Gender

Other

Playing Experience (if any)

Would you be interested in volunteering at MBUSC?

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Do you have any allergies, chronic illness, or medical conditions? If yes, please describe.

Are you prescribed an inhaler or medication that may be required at training? If yes, please explain any instructions.

Medical Release and Authorization

I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact the named Emergency Contact in the most expeditious way possible.

Permission is also granted to the Mount Barker United Soccer Club and its affiliates including Directors, Coaches, etc to provide the needed emergency treatment prior to admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of myself.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature