PLACE COLOR COPY OF ID HERE:
PLAYER REGISTRATION FORM

Player's Name: __________________________________________TEAM:

Date of Birth: _______________M: __________F: __________

Address: __________________________________________________________

E-mail address: ____________________________________________________

Home Phone #: _____________Work Phone#______________

My Insurance Co. is: _________________________________ SS#: _______________

My Policy Number is: __________________________________________________

Family Physician: ________________________________________________

In case I cannot be reached, any of the following persons is designated to act on my behalf.

Emergency Contact: ________________________Phone: __________________

Address: __________________________________Phone: _________________

Known Allergies or any other medical information we should be aware of:

 

 

WAIVER OF LIABILITY, MEDICAL RELEASE FORM AND DISCLAIMER   I give my consent and agree to release, indemnify, and hold harmless Southwest Adult Soccer League, Southwest Soccer Club, SWSC staff, the JBMSC and all personnel, including officials, representatives, and field owners from any claim arising from any injury. Furthermore, I give my consent for emergency medical treatment. This release is effective for the period of one year from the date given below.  I also assume the responsibility for payment of any such treatment.

Signature: _________________________________Date ___________________

FYI:  YOU MUST ALSO PROVIDE A COLOR COPY OF A CURRENT PICTURE ID.