Chenango Chargers Soccer Club

Last
Name _________________________

First
Name _______________________

Address _______________________

City ________________________

State _________ Zip Code _______

(Area Code) Telephone #

_____________________________

(MM/DD/YR) Birth date __________

Sex ______ M _______ F

Parent’s E-Mail Address _______________________

Player’s E-Mail Address _____________________

Father’s
Name _________________________

Mother’s
Name _______________________

Work Phone # __________________

Work Phone # ________________

Emergency Contact ______________

Emergency Phone # ____________

Player Height _____ Weight _______

Uniform Size __________________

IMPORTANT

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and /or otherwise indemnify the USYS, its affiliated organizations and sponsors, their employees and associated personnel, including the owners 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 transportation I hereby authorize.

DATE_______ Name ______________________________________

Consent for Medical Treatment

As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine, or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my descendent.

X

Signature of Parent or Guardian

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