St Pauls Soccer Association Inc
Elite Academy FC RECREATION/TRAVEL/SHOWCASE SOCCER PROGRAM REGISTRATION FORM 2019 SPRING 648 N Old Stage Road St Pauls, NC 28384 (910).616.3872 www.eliteacademyfc.org
PLAYER INFORMATION New or Returning Player*: (check one)
* required field
[ ] New
** at least one field required
[ ] Returning
Has the Player Previously played with our program*: (check one)
[ ] Yes[ ] No
Does the player have a sibling in the same division*: (check one)
[ ] Yes[ ] No
Player Name*: _____________________________________________________ Date of Birth*: _________________ Address*: __________________________________ City*: __________________ State*: ______ Zip*: ____________ Home Phone**: ______________________________ Mobile Phone**: __________________________________ e-mail*: __________________________________________ Height*: ______________ Weight*: ________________ Current School*: ____________________________________________________ Current Grade*: _____________ Years of Soccer Experience*: ___________ Shirt Size*: (circle one) Shorts Size*: (circle one)
S
M
L
XL
YM
YL
S
Socks Size*: (circle one)
M
L
XL
S
M
L
If applicable, list any medical conditions that we may need to be aware of: ____________________________________ __________________________________________________________________________________________________
PARENT INFORMATION Parent Name*: __________________________________________________ Relation*: ________________________ Gender*: (check one)
[ ] Male
[ ] Female
Age*: ____________
Emergency Contact Number #1**: ____________________________________________ Emergency Contact Number #2**: ____________________________________________ e-mail*: __________________________________________________ Parent Volunteer/Support Type Requested*: (check any type that you would like to volunteer for) We are constantly looking for parental support for our program. Consider becoming a volunteer on some match days and for specific teams to help with our organization. Please select any of the following that you would be interested in. [ ] Coach [ ] Assistant Coach [ ] Concession [ ] Fundraising
[ ] Manager
[ ] Referee
[ ] Board Member
FOR CLUB/LEAGUE USE ONLY Date Received: ______________________________ Copy of Birth Certificate Received: ____________________________________ Payment Received: ___________________________________ Cash Payment or Check #: _______________________________________
[ ] Fields
NORTH CAROLINA Medical Consent / Waiver of Liability and Release (To be given to your local association) 19 20 20 ____ - 20____
NCYSA
NCYSA Policy # Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.
PO Box 18229 Greensboro, NC 27419 336.856.7529
St Pauls Soccer Association (Elite Academy FC) Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)
Full Association Name [ ] Academy
[ ] Challenge
Birth Date
[ ] Classic
Jersey # [ ] Recreation
[ ] Male
Level
[ ] Female Sex
Address of Player
City
State
Zip
Parent/Legal Guardian Full Name
Home Phone
Work Phone
Cell Phone
Additional Person to Contact in an Emergency
Address
Home Phone
Cell Phone
Date of Last Tetanus Shot
Medications now being taken
Player is Allergic to these Medications and Substances Parent Email For Soccer Information
List any Unusual Health Information
I (we), the undersigned, residing in the county of , state of _________, the parents/legal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we 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 and NCYSA accepting the Registrant for their soccer programs and activities (the “ Programs”), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by 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 we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize any one of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing. Insurance Information: Name of Insurance Company:
**Parent/Legal Guardian Signature
ID Number:
**No Electronic Signature Permitted
Confirmation Number:
_____________________________________________ Date
Original (Team)
Copy (Association)
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.
Club Name: League Name:
St Pauls Soccer Association (Elite Academy FC)
City:
State:
St Pauls
NC
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. [Note: it will not be necessary to complete this form again as long as the player is with this club, which will hold this form unless requested by US Club Soccer.]
___________________________________ _____________ Player’s Signature Date
________________________________ _____________ Parent/Guardian Signature Date
PLAYER’S MEDICAL INFORMATION Player’s Name:
Street Address: State: Parent Name:
Birth Date:
City: : Zip
Female ☐ Male ☐
Email Address:
Email Address: Parent Name:
Gender:
Email Address:
Home Phone:
( )
Cell Phone: Home Phone:
( ) ( )
Cell Phone:
( )
Bus Phone: Receive texts? Bus Phone: Receive texts?
In an emergency when parent/guardian cannot be reached, please contact the following: Name: Phone 1: ( ) Phone 2: Name: Phone 1: ( ) Phone 2:
( ) ☐Yes ☐No ( ) ☐Yes ☐No
(
)
(
)
Please list player allergies: Please list other medical conditions:
Physician:
Phone 2:
(
)
Medical/Hospital Insurance Company:
Phone 1:
(
)
Phone:
)
Policy Holder’s Name:
Policy Number:
(
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 Form #R002-Y – 5/2012
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.
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: _________________ Relation to player: ☐ Father ☐ Mother ☐ Guardian
Form #R002-Y – 5/2012
FORMULARIO DE INSCRIPCIÓN PARA JUGADORES JUVENILES Este formulario debe permanecer con el club durante al menos cinco (5) años o hasta que el jugador tenga 18 años, lo que ocurra después.
St Pauls Soccer Association (Elite Academy
Nombre del Club: FC) Nombre de la Liga:
Ciudad:
Estado :
St Pauls
NC
Por la presente, doy consentimiento al club4 anteriormente nombrado a registrarme con US Club Soccer. Entiendo que en cualquier momento puedo estar registrado con sólo uno de los clubes miembros de US Club Soccer. [Nota: No es necesario rellenar este formulario en cuanto el jugador sigue con este club. El formulario permanecerá con el club, a no ser de que US Club Soccer lo solicite.]
___________________________________ _____________ Firma del jugador Fecha
________________________________ _____________ Firma del padre/tutor Fecha
INFORMACIÓN MÉDICA DEL JUGADOR Nombre del jugador: Dirección:
Día de nacimiento:
Estado:
Ciudad: Código Postal:
Nombre del Padre:
Female ☐ Male ☐
Email: Teléfono (Casa): Celular: Teléfono (Casa): Celular:
Email: Nombre de la Madre:
Género :
Email:
( )
Teléfono (Trabajo)
(
)
( )
Recibe Texto/SMS?
☐Si ☐No
( )
Teléfono (Trabajo)
(
( )
Recibe Texto/SMS?
☐Si ☐No
En el caso de emergencia cuando no se puede contactar con el padre/tutor, por favor, llame: Nombre: Teléfono 1: ( ) Teléfono 2: ( Nombre: Teléfono 1: ( ) Teléfono 2: (
)
) )
Por favor haga una lista de alergias: Por favor, haga una lista de otras condiciones médicas: Médico:
Teléfono 1:
Compañía de seguros médicos:
Titular de la póliza:
(
)
Teléfono 2:
(
)
Teléfono:
(
)
Número de póliza:
AUTORIZACIÓN DE TRATAMIENTO MÉDICO Y RENUNCIA A LA RESPONSIBILIDAD Por la presente, doy consentimientos a que los entrenadores físicos, los entrenadores técnicos, los gerentes, los directores médicos, los técnicos de emergencia médica, los enfermeros, las instalaciones de tratamientos médicos, y/o el doctor de medicina o de odontología, o personal asociado, proporcionen asistencia médica y/o tratamiento al participante y me comprometo ser financieramente responsable por todos los gastos de cualquier asistencia y/o tratamiento. Entiendo que el tratamiento de lesiones se basará en la información en este formulario. Por la presente, autorizo transportación de urgencias del participante a la instalación de tratamientos médicos cuando cualquier individual anteriormente mencionado considera que es necesario. Reconozco la posibilidad de daños físicos asociados con el fútbol, y por este medio libero, descargo, y de cualquier manera, indemnizo a mi club y a mi equipo, US Club Soccer, sus patrocinadores, US Soccer Federation y las organizaciones afiliadas, y los empleados y personal asociado con Form #R002-Y – 5/2016
FORMULARIO DE INSCRIPCIÓN PARA JUGADORES JUVENILES Este formulario debe permanecer con el club durante al menos cinco (5) años o hasta que el jugador tenga 18 años, lo que ocurra después. dichas organizaciones, contra cualquier demanda legal del jugador como resultado de la participación del jugador en los programas de US Club Soccer y/o en el transporte desde y a cualquier de estos programas, que por la presente también autorizo.
Firma: _______________________________________ Fecha: _________________ Relación al jugador: ☐ Padre ☐ Madre ☐ Tutor
Form #R002-Y – 5/2016
