Athens United Soccer Assocation

Spring 2017

Player Registration Form

Player Name ______

Phones: (H)______(C) ______

Home Address: ______

______

City ______Zip ______

Gender ______BirthDate______HS Grad Year ______

Email Address ______

Parent/Guardian Name ______

INFORMED CONSENT/INSURANCE NOTICE

Insurance Notice: All injuries must be reported within 90 days of the date of the injury.

Informed Consent: I, the Parent/guardian of the registrant, agree that we will abide by the rules of Athens United Soccer Association, Georgia Soccer, and all of its affiliated organizations. My child wishes to participate in soccer during the season of this registration. I realize risks are involved in my child’s participation. I understand that the risk to my child includes full range of injuries from minor to severe, and the result could be death, paralysis, or other serious, permanent disability. I accept this risk as a condition of my child’s participation.

In case of an emergency, if physicians cannot be reached, I hereby authorize the club/coach and or volunteers to contact certified emergency personnel(paramedic, EMT, ER, etc) and authorize my player to be treated by the same. I agree to abide by the rules of the club, its affiliated organizations, and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the club accepting this player for its TOPsoccer program and activities, I hereby release, discharge and/or otherwise indemnify the club, its affiliated organizations, and sponsors, their employees, volunteers and associated personnel, including the owners of the fields and facilities utilized for the programs, against any claim by or on behalf of the player as a result of the player’s participation in the programs.

Parent/Guardian Signature: ______Date: ______

Print Name ______

Supplemental Information Form

Please tell us what your child’s disability, impairment or condition is so that we can better serve you.

______

Are there any limitations or behavioral concerns that we and our volunteers should be aware of?

______

Mobility Aids used:

Walker ______Other ______

Health Aids used:

Hearing Aid: ______Glasses: ______other ______

Please list any medications your child is taking and any allergies he/she may have. ______

______

Physician Name and Telephone: ______

Is your child a resident of a group home? If so, please complete the following information.

Agency Name: ______Supervisor Name: ______

Address and Telephone:

______

**A PARENT/GUARDIAN OR GROUP HOME EMPLOYEE MUST REMAIN AT THE FIELDS AT ALL TIMES AND ASSIST PLAYER IF NECESSARY.**