PLAYER

MEMBERSHIP FORM

Revised 04-2004

____ PRIMARY TEAM ____ SECONDARY TEAM

2050 N. Plano Road, Suite 100

Richardson, TX 75082

1800-4-SOCCER

1-214-235-4499

Youth Division of US Soccer

Affiliated with the Federation

Internationale de Football

Association (FIFA)

LAST FIRST

NAME _________________________________________________ NAME _____________________________________________ INITIAL _____

ADDRESS _____________________________________________________CITY _______________________ STATE_____________ZIP_______________

________ BORN IN THE UNITED STATES? ________YES ________NO

PHONE (_______) ________-___________ BIRTHDATE _______________ MALE (M) OR FEMALE (F) IF NOT, WHERE?

_______________________

FATHER’S NAME ______________________________ ADDRESS __________________________________________________________________

IF DIFFERENT FROM ABOVE

OCCUPATION ________________________ HOME (_____) _____-____________ WORK (____) ______-__________ CELL (____) ______-__________

IF DIFFERENT FROM ABOVE

MOTHER’S NAME _____________________________ ADDRESS __________________________________________________________________

IF DIFFERENT FROM ABOVE

MOTHER’S BIRTHDAY (MM/DD ONLY (ONLY USED TO CREATE UNIQUE ID NUMBER)

OCCUPATION ________________________ HOME (_____) _____-____________ WORK (____) ______-__________ CELL (____) ______-__________

IF DIFFERENT FROM ABOVE

ALTERNATE PERSON TO NOTIFY IN AN EMERGENCY _________________________________________ PHONE (______) _________-_______________

DOCTOR TO NOTIFY IN AN EMERGENCY ___________________________________________________________________ PHONE (_________) ____________ - __________________

LIST ALL MEDICAL CONDITIONS OF PLAYER ______________________________________________________________________________________

NO. OF PRIOR SEASONS PLAYED _____ LAST TEAM _____________________ LAST LEAGUE __________________ DATE OF LAST SEASON ___________

SCHOOL ____________________________________ PARENTAL SUPPORT: ______COACH ______ASST. ______MGR. ______BOARD ______ OTHER

WE ASK FOR ACTIVE PARTICIPATION; PLEASE CHECK AREAS OF INTEREST.

OTHER CHILDREN ____________________________________________ AGE ______ *OPEN REGISTRATION:

FROM FAMILY PREFERRED LOCATION OF TEAM ASSIGNMENT?

PRESENTLY IN LEAGUE ____________________________________________ AGE ______ ****** ____________________________________________________________

PLEASE PRINT ALL INFORMATION LEGIBLY

IMPORTANT

I, the parent/guardian of the below named player, agree that I and the player will abide by the rules and regulations of US Youth, KSYSA, SCSA, all other affiliated organizations and its sponsors (“US Youth Parties), in consideration of the player’s participation in the soccer programs and activities of the US Youth Parties (the “Programs”), I, for myself and the players and my respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the US Youth Parties, the City of Wichita, Sluggers (Cooperstown d.b.a.), all other owners and operators of the facilities used for the Programs and their respective directors, officers, employees, agents, coaches, referees, and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with my participation in the Programs including without limitation, player’s transportation to/from any Program, which transportation is hereby authorized. I further grant the US Youth Parties the right to use the player’s name, picture and/or likeness in printed, broadcast and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player’s status as a participant in the Programs.

_______________________________ ________________________________ __________

PARENT NAME (PLEASE PRINT) SIGNATURE DATE

____________________________________________________ ______________________________________________________ ________________

PLAYER NAME (PLEASE PRINT) SIGNATURE DATE

CONSENT FOR MEDICAL TREATMENT (Minor) As the parent or legal guardian of the above named player, I hereby give 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 dependent. Signature of Parent or Guardian ____________________________________________________________________ PRINTED NAME ____________________________________________________________________ SIGNATURE

OFFICE USE ONLY: Picture Received: _____ Yes _____ No Birthdate Verified: _____ Yes _____ No Player Registration Fees: $ ______________ Other $ ______________ Total $ ______________ ______ Cash ______________ Check Number _______________ Date ______________ Received By