How Ponyboy Changes Throughht the Outsiders

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  • Topic: Medicine, Emergency medical technician, E-mail
  • Pages : 2 (384 words )
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  • Published : May 18, 2013
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716 8th Ave. North Myrtle Beach, SC 29577 Phone: (843) 429-0006 Email: admin@usclubsoccer.org Website: www.usclubsoccer.org

YOUTH CLUB REGISTRATION CONFIRMATION
Club Name: League Name:
City: State:

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: Email Address: Parent Name: Email Address: Zip : Email Address: Home Phone: Cell Phone: Home Phone: Cell Phone: ( ( ( ( ) ) ) ) Bus Phone: Receive texts? Bus Phone: Receive texts? ( ) Yes ( ) Yes Birth Date: City: Gender: Female Male

No No

In an emergency when parent/guardian cannot be reached, please contact the following: Name: Phone 1: ( ) Phone 2: Name: Please list Allergies the player has: Please list other medical conditions: Physician Medical/Hospital Insurance Company Policy Holder’s Name Phone 1 ( ) Phone 2 Phone Policy Number Phone 1: ( ) Phone 2:

( (

) )

( (

) )

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...
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