EmailMe Form - Ebony City Socer Club - Player Registration Form

Player's Full Name *

Player's Gender *

Player's Birth Date *

MM / DD / YYYY

Player's Age *

Player's Address *

Street Address City State / Province / Region Postal / Zip Code Country / Region

Player's School *

Player's Shirt & Shorts Size *

Player's Height *

Player's Weight *

PARENT INFORMATION

Please fill out as much information as you can so we can best serve you and your family.

Mom's Name *

First Last

Mom's Phone *

### - ### - ####

Mom's Work Phone

### - ### - ####

Mom's Email

Dad's Name *

First Last

Dad's Phone

### - ### - ####

Dad's Work Phone

### - ### - ####

Dad's Email

Parent Participation

We ask for 4 hours of active participation of all parents in our program. Please check Area(s) in which You are able to help. You will be contacted prior to the start of season by a board member. Thanks! *

PLAYER MEDICAL INFORMATION

Doctor's Name *

Doctor's Phone

### - ### - ####

Please list any player medical problems or prohibitions. (write "none" if appropriate) *

Release Statement and Medical Consent: *

First Last

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the Ebony City Soccer Club, SC Youth Soccer Association, The United States Youth Soccer Association . Youth Division of the United States Soccer Federation (USSF), affiliated with the Federation International de Football Association (FIFA), its affiliated organizations and sponsors. Recognizing the possibility of injury associated with soccer and in consideration for the Ebony City Soccer Club, SC Youth Soccer Association, and the US Youth Soccer accepting the registrant for its soccer programs and activities (the “Program”), I hereby release, discharge and otherwise indemnify the Ebony City Soccer Club, SC Youth Soccer Association, US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities used 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. As the parent or legal guardian of the above-named player, I also hereby give my 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 child/children.

ADDITIONAL INFORMATION

Today's Date *

MM / DD / YYYY

No Refunds *

I understand

NO REFUNDS after final team forms are filed with LSYSA (Lower State Youth Soccer Ass). Please confirm that you understand this policy

Official Use Only