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: __________________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. I also understand that some officials are still in training and have not yet been certified. Furthermore, I give my consent for emergency medical treatment. I also assume the responsibility for payment of any such treatment. This release is effective for the period of two years from the date given below.

Signature: _________________________________Date ___________________
 

FYI: YOU MUST ALSO PROVIDE A COLOR COPY OF A CURRENT PICTURE ID. (2006)