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Kansas Youth Soccer Association Membership & Medical Release Form

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Kansas Youth Soccer Association Membership & Medical Release Form
Kansas Youth Soccer Association Membership & Medical Release Form
KANSAS YOUTH SOCCER ASSOCIATION
MEMBERSHIP & MEDICAL RELEASE FORM
LEAGUE USE ONLY
New Registration
Transfer
Change / Correction
League Name
Age Group
Club/Team Name Division
Last Name First Name MI
Address City State Zip
Phone
Birthdate
Male
Female
E-Mail Address
Father's Name Occupation Cell Phone
Mother's Name Occupation Cell Phone
Mother's Birthday (month & day only)
Mother's month and day of birth is collected only to create a unique record for each participant.
List any medical problem or prohibition play has
Person to notify in emergency Phone
Doctor to notify in emergency Phone
# Seasons Played Last Team Last League
Height Weight School Grade
UNIFORM SIZE
Shirt
Shorts
Socks
XS XLLMS XS S M L XL
Relationship
PARENTAL SUPPORT
Coach
Asst. Coach
Team Manager
Team Parent
Special Projects
Field Preparation
Board Member
Publicity
Committee
Referee
Fund Raising
Clerical
Reporter
Newsletter
Concessions
Donor
PARENTS APPROVAL AND MEDICAL RELEASE
In consideration for being allowed to participate in any way in the USSF sanctioned play, including play sanction by the US Youth Soccer Association and the Kansas State Youth Soccer Association, as a player in games,
training activities and exercises, and related events and activities, the undersigned:
1. Agree that the parent(s) and or legal guardian(s) together with their minor participant will, prior to participating, inspect the facilities and equipment to be used, and if they or the participant believe anything is unsafe,
he or she should immediately advise his or her coach or supervisor of such condition(s) and refuse to participate.
2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and severe social and economic losses which might
result not only from their own actions, inaction or negligence, but the action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other
risks not known to us or not reasonably foreseeable at this time.
3. Assume all foregoing risk and accept personal responsibility for damages following such injury, permanent disability or death.
4. Release, waive, discharge and covenant not to sue US YOUTH SOCCER ASSOCIATION, KANSAS STATE YOUTH SOCCER ASSOCIATION, their affiliated clubs, their respective administrators, directors, agents, coaches and
other employees of the organizations, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event, all of which are hereinafter referred to a
"releasees," from any and all LIABILITY to the participant and the undersigned, his or her heirs and next of kin for any and all claims, demands, losses or damages on account of injury, including death or damage to
property, caused or alleged to be caused in whole or in part by the negligence of the releasees or otherwise.
5. 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.
I/WE HAVE READ THE ABOVE WAIVER AND RELEASE, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY. The Information above and medical history supplied is
correct to the best of my knowledge.
Name of Parent/Legal Guardian (please print)
Signature Date
OFFICIAL USE ONLY
Picture Received
Birthdate Verified
Registration Fees:
Player Fee:
Coach's Fee:
Other Fee: Received By:
Date
TOTAL:
Cash: Check #: Check $:
Notary Public
Subscribed and Sworn to me this: Day of 20
Signature
My Commission Expires
Exclude from mailing and email lists
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Kansas Youth Soccer Association Membership & Medical Release Form