Tidal Wave SC Registration for Seasonal Year 2014-2015

Tidal Wave SC Registration for Seasonal Year 2018-2019

* Indicates Required Field

(Tryout registration database is not linked to GotSoccer or other mass databases)

Player"s Last Name *

Player"s First Name *

Street Address *

City *

State *

Zip code *

Player Date of Birth *

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Player Gender *

Grade (in Fall 2018) *

Home Phone number *

Player e-mail address

Preferred e-mail address *

Player Cell #

Mother"s Name *

Mother"s e-mail *

Mother"s Cell # *

Mother"s Address (Or enter same) *

Father"s Address (Or enter same) *

Father"s Name *

Father"s e-mail *

Father"s Cell # *

Medical Background and Information & Emergency Contact information

Emergency Contact Name *

Contact Cell # *

Contact Home Phone *

Please list any medications including those which are maintenance medications (i.e. Diabetic, Asthma, Seizure Disorder.) The purpose of providing this information is to ensure that medical personnel have details of any medical problems which may interfere with or alter treatment.

Allergies *

Other Medical Conditions *

Medication(s)

Dosage & frequency of Dosage

Physician Name *

Physician Phone *

Medical/Hospital Insur. Company *

Insurance Co. Phone *

Policy Holder"s Name *

Policy Number *

Recognizing the possibility of physical injury associated with soccer and in consideration for the USSF/US Club Soccer and its affiliates accepting the registration for its soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the USSF/US Club Soccer and its affiliated organizations and sponsors, their employees and associated personnel, including the owner of fields and facilities utilized for the Programs against any claim by or on behalf of the registrant as a result of the registrant"s participation in the Programs and/or being transported to or from the same, which is transportation I hereby authorize. My son/daughter has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment.

Electronic Signature: By typing in your name below you agree that this represents your legal signature and that this electronic signature is valid in all legal situations where a handwritten signature applies and is valid.

I agree to Electronic Signature statement above *

Typed electronic signature *

Date *

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