2018-2019 Zachary Area Middle School Soccer Program Registration Form

All fees are non-refundable. Checks will be made payable to your coach. Collection of fees at first team meeting. Uniform is yours to
keep. Once chosen, no guarantee of playing time at this level of play.
Please Print:
Player’s Name: Date of Birth:
Home Address: City: Zip:
Mother’s Name: Cell #: Work #:
Father’s Name: Cell #: Work #:
Mother Email: Player Email:
Father Email: Player Cell#:

Acute Medical History of:

Medication on hand for administration as needed:
Emergency Contact (other than parents, if needed): Phone:
Physician to notify if parents/guardian is unavailable: Phone:
Medical facility of choice:

I, , the parent/legal guardian of athlete listed above, a minor, agree that the athlete and I will abide by
the rules of the USYSA, its affiliate organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in
consideration for 2018-2019 Zachary Area Middle School Soccer Program accepting the athlete for its soccer program, I hereby release, discharge
and/or otherwise indemnify the, BRSC/BRSA, USYSA its affiliate organizations, the coach(es) and sponsors, their employees and associated personnel
including the owners of the fields and facilities utilized for the programs, against any claim by or on the behalf of the athlete as a result of the athletes
participation in the program and/or being transported to/from the same which transportation I hereby authorize.

Date:
Parent/Guardian Signature

Consent for Medical Treatment (Minor)

As parent/legal guardian of the above mentioned athlete, I hereby give my consent for emergency medical care as prescribed by a dually
licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life,
limb, or well being of my dependent. I understand I am responsible for any and all payment for treatment.

Signature: Relationship: Date:

Medical Insurance Provider: Address:
Phone Number: Group Number: Member ID:

In consideration of , my minor child being allowed to participate in the 2018-2019 Zachary

Area Middle School Soccer Program, related events and activities, the undersigned agrees that participants’ likeness may be
photographed or videotaped and that such image may be published in an outlet used to promote or publicize the sports program.

Date:
Parent/Guardian Signature

Print Parent/Guardian Name

Grade for school year 2018-19: 5th Grade Years of soccer experience: Years School:
Did you play BRSC Club or Recreational Soccer in the Fall 2018? Select Jersey Size: Jersey Size

Yes: No: If so, which team(s)? Select Short Size: Short Size

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