Myrtle Beach, SC 29577

Phone: (843) 429-0006

Email: admin@usclubsoccer.org

Website: www.usclubsoccer.org

CLUB REGISTRATION CONFIRMATION

Club Name_________________________________ City__________________________ State_________

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 Date Parent/Guardian Signature Date

______________________________________________________________________________________

PLAYER’S MEDICAL INFORMATION

Player’s Name___________________________________________Birthdate________________

Street Address________________________ City__________________________ Zip___________

Father’s Name____________________ Home Phone (___)_____________Bus Phone (___)_______________

Mother’s Name_________________ Home Phone (__)______________ Bus Phone (___)_________________

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

Name_________________________ Home Phone (__)______________ Bus Phone (___)______________

Name_________________________ Home Phone (__)______________ Bus Phone (___)______________

Allergies_______________________________________________________________________________

Other Medical Conditions_________________________________________________________________

Physician______________________ Home Phone (___)_____________ Bus Phone (___)______________

Medical/Hospital Insurance Company____________________________ Phone (__)______________________

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/participant to a medical treatment facility should an individual listed above consider it to be warranted

Signature

________________________________ (Relation to player: father, mother, guardian