CFSC US CLUB SOCCER YOUTH PLAYER REGISTRATION FORM
This form must be retained by the club for at least five (5) years or until the player’s 18th birthday, whichever occurs last.
Player's First and Last Name *
Your answer
Birth Date *
MM
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DD
Birth Year *
Your answer
Gender *
Street Address *
Your answer
City *
Your answer
State *
Your answer
Zip *
Your answer
Email Address *
Your answer
Parent Name *
Your answer
Home Phone *
Your answer
Cell Phone *
Your answer
Additional Parent Name
Your answer
Additional Parent Email
Your answer
Additional Cell
Your answer
Emergency Contact 1 *
Your answer
Emergency Phone 1 *
Your answer
Emergency Contact 2 *
Your answer
Emergency Phone 2 *
Your answer
Player Allergies *
Your answer
Other Medical Conditions *
Your answer
Physician *
Your answer
Physician Phone *
Your answer
Medical Insurance Company *
Your answer
Medical Phone Number *
Your answer
Policy Holder Name *
Your answer
Policy Number *
Your answer
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 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.
Parent Signature *
Your answer
Date *
MM
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DD
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YYYY
Relation to Player *
Signature Consent
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.
Player's Signature *
Your answer
Date *
MM
/
DD
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YYYY
Parent/Guardian Signature *
Your answer
Date *
MM
/
DD
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YYYY
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