US Club Soccer Form

Member of the United States
Soccer Federation

7 716 8th. Ave. North
8 Myrtle Beach, SC 29577
9 Phone: (843) 429-006
10 Email:admin@usclubsoccer.org
11 Website: www.usclubsoccer.org

Registering for: *

CLUB REGISTRATION CONFIRMATION

Club Name *

City *

State *

Team:

Please email me updates

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 necessarey to complete this form again as long as the player is with this club.]

Player Signature (type name) *

Parent/Gardian Signature (Type name) *

Date *

PLAYER MEDICAL INFORMATION

Player's Name *

Birthdate *

Age Group *

Gender *

Street Address *

City *

zip *

Father Name *

Father's Home Phone *

Father's Cell Phone *

Mother's Name *

Mother's Home Phone *

Mother's Cell Phone *

Father's Email Address *

Mother's Email Address *

In an emergency when parent/gardian cannot be reached, please contact the following:

Emergency Contact Person *

Emergency Person Home Phone *

Emergency Person Cell *

Emergency 2 Contact Person *

Emergency 2 Home Phone *

Emergency 2 Person Cell *

Allergies *

Other Medical Conditions *

Physician *

Physician phone *

Medical / Hospital Insurance Company *

Medical / Hospital Insurance Phone *

Policy Holder's Name *

Policy Number *

EMERGENCY MEDICAL TREATMENT AUTHORIZATION

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 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.

*

(Agreement for Electronic Submission) By checking this box and submitting this e-Registration form, I acknowledge that: I am the parent/guardian authorized to consent on the player’s behalf; I have reviewed this form and the information in contains and represent that it is accurate; and I agree to submit this form electronically with the intent to be bound by its terms and conditions.

Parent / Gaurdian Signature (type name) *

Relation to player *

Date *

Please attach JPEG format Birth Certificate <700kB and JPEG pictures <300kB.

Please attach separate COLOR photo (Black and White not acceptable)Pictures must be update yearly: One of player's face and another picture of player's Birth Certificate. Only Jpeg images < 700kb. Please DO NOT use scanned images. instructions: Take a picture with a digital phone or camera of each item, send it to yourself via email and save them to your computer then upload it to the website.

Copy of Birth Certificate (Jpeg Format) *

Player Picture (1in x 1 in face only) (Jpeg Format) *

Completed forms will be sent to: *

Al Marra - Club Registrar

Dani Giulvezan - Club Administrator