HSA little BOOTERS Registration

 

Player Name:  _______________(first) _______________(last)

 

age as of July 31st: _____

 

Mother Name:  _______________(first) _______________(last)

 

phone:  _______________

 

email:   _______________

 

Father Name: _______________(first) _______________(last)

 

phone: _______________

 

email:  _______________

 

Address:          ________________________________________

 

________________________________________

 

________________________________________

 

Player shirt size: YXS YS YM YL YXL S M L XL XXL

 

Parent shirt size: (optional for $15) _____

 

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.  I recognize the possibility of physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify Hinshaw Soccer Academy, their sponsors, 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.

 

Signature_________________________________             Date____________________