League Age: 6-8, 9-11 G, 9-11 B, 12-14 or 15-18 Tryout: Y / N Registration $30 paid: Y / N

Returning Player: Y / N IF YES: team name and player age played last year____________________

Shore Soccer League Player Registration & Medical Release

Player Information

Player Name ________________________ Date of Birth _______________________

911 Address ________________________ Gender M F

Mailing address ______________________ Home Phone: 757-___________________

___________________________________

Parent Information

Parent __ __________________________ Parent __ ________________________

Phone: 757-_______________________ Phone: 757-_____________________

Volunteer _______Y________N Volunteer ______Y________N

Email _____________________________ Email ___________________________________

Medical information

Insurance Carrier ____________________ Policy # ____________________________________________

Family Physician ____________________ Phone: 757-_________________________________________

Address: ________________________________________________________________________________

Please list any allergies/medical problems, including those requiring maintenance medication (i.e. diabetic, Asthma, Seizure Disorder, etc. )

Medical Diagnosis Medication Dosage Frequency of Dosage__________________

__________________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

Additional emergency contact (other than parents listed above):

Name: ______________________________ Phone: 757-____________________________

In case of emergency, if family physician cannot be reached, I herby authorize my child to be treated by Certified Emergency Personnel (i.e. EMT, First Responder, E.R. Physician)

IMPORTANT INFORMATION: (Please read before signing)

By signature below, we hereby agree that the Shore Soccer League, it’s members, coaches or officers shall not be liable for any injury or loss which my child or children may sustain while participating in activities of any kind, whether sponsored by or under supervision of the Shore Soccer League and we agree to indemnify and to hold harmless the Shore Soccer League, its members, coaches, officers, or designates of any kind from claim whatsoever.

______________________________________________ _________________________

Authorized Parent/Guardian Signature Date