Player contact and medical info

Player Name *

First Name

Last Name

Date of birth *

MM

DD

YYYY

Parent 1 Phone *

(###)

###

####

Parent 2 Phone *

(###)

###

####

Primary physician contact number *

(###)

###

####

Player has health insurance that covers needs? *

Has insurance

Does not have insurance - parent accepts responsibility

Injury release *

Recognizing the possibility of injury or illness, and in consideration for James United FC accepting my son/daughter as a player in the soccer program and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify James United FC, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer.

Accept

Do not accept