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SSC Player Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

Persons Having Legal Custody of Child:

If previous selection "other", indicate who:

* Street:

* City:

State:

* Zip Code:

* Home Phone:

* Birthdate (mm/dd/yyyy):

* Email:

* Gender:

* Age Designation (Birth Year for 2018-2019):

Team Name:

Jersey Number:

* if returning

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* EMail:

Home Phone:

Work Phone:

* Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Player:

* Insurance Carrier:

* Policy #:

Physician's Name:

Physician's Telephone #:

Does the player have any medical, orthopedic, or emotional condition that we should be aware?:

If yes, please indicate nature of condition:

Players' Allergies:

Date of last Tetanus shot (month/date):

CONSENT FOR MEDICAL TREATMENT/LIABILITY RELEASE

Soccer is at times a physical, contact sport. As the parent or guardian of the players enrolled in the Smithfield Soccer Club's program, I understand that these programs, activities, games and training elements are hazardous by nature and I assume all risks of injuries arising from participation. I release, indemnify and hold harmless the Smithfield Soccer Club, its directors, employees, staff and facility (IOW Parks and/or Schools, etc.) from any claim, demand or action arising in connection with the player's participation.

Personal medical insurance is required. If the player requires medical attention every effort will be made to contact the player's parents, guardians or emergency contacts. In the case of an emergency, the players will be provided emergency medical services prior to informing the parent or guardian. I assume responsibility for any costs incurred in treating the player. I waiver any liability or accountability to the Smithfield Soccer Club or the facility (IOW Parks and/or Schools, etc.) for the quality or cost of medical services provided.

The player's parent or guardian is responsible for any property damage caused by the player. Smithfield Soccer Club or facility (IOW Parks and/or Schools, etc.) accepts no responsibility for the loss or damage to a player's property.

I give permission to the Smithfield Soccer Club to use my player's picture or likeness in promotion of the Smithfield Soccer Club in printed or electronic media. I renounce any claims upon Smithfield Soccer Club for reimbursement for use of this material.

I/we have read and accept the Smithfield Soccer Club's Policy Statement *

* indicates required fields

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SSC Player Registration Form