UPPER 90 FC
NEW PLAYER PACKET CHECK LIST
FALL 2017 – SPRING 2018
•
US Club Waiver and Release of all Claims
•
Ohio North Youth Soccer Association Membership Form
•
UPPER 90 FC Medical Release Form
o NOTE: The medical release form MUST be notarized
•
UPPER 90 FC Code of Conduct
o Athlete
o Parent(s) – All parents / legal guardians need to sign the form
•
Copy of Birth Certificate
•
Copy of Insurance Cards (front and back)
Complete the registration packet and bring it to tryouts
Electronic copies of these forms can be found at forms.upper90futbolclub.com
YOUTH PLAYER REGISTRATION FORM
This form must be retained by the club for at least five (5) years or until the player’s 18th birthday, whichever occurs last.
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:
Birth Date:
Street Address:
Gender:
Female
Male
City:
State:
Zip :
Email Address:
Parent Name:
Home Phone:
(
)
Bus Phone:
Email Address:
Cell Phone:
(
)
Receive texts?
Parent Name:
Home Phone:
(
)
Bus Phone:
Email Address:
Cell Phone:
(
)
Receive texts?
( )
Yes
No
( )
Yes
In an emergency when parent/guardian cannot be reached, please contact the following:
Name:
Phone 1:
( )
Phone 2:
( )
Name:
Phone 1:
( )
Phone 2:
( )
Phone 1:
( )
Phone 2:
( )
Medical/Hospital Insurance Company:
Phone:
( )
Policy Holder’s Name:
Policy Number:
No
Please list player allergies:
Please list other medical conditions:
Physician:
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 individual listed above consider it to be warranted. I recognize the possibility of
physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify the club, US
Club Soccer, their sponsors, the USSF and its affiliated organizations, and the employees and associated
personnel of these organizations, against any claim by or on behalf of the soccer player named above as a
result of that player’s participation in US Club Soccer programs and/or being transported to or from the same,
which transportation I hereby authorize.
Signature: _______________________________________ Date: _________________ Relation to player:
Father
Mother
Guardian
Form #R002-Y – 5/2012
Ohio North Youth Soccer Association
20___ - 20___ SEASONAL YEAR
☐ FALL ☐ SPRING ☐ SUMMER
YOUTH PLAYER REGISTRATION APPLICATION
Parent/Guardian Information
First Name*
* Required Field
Last Name*
M.I.
**At least one field is required
Relation to Child*
Street Address*
Apartment/Unit #
City*
State*
Home Phone**
Zip*
Work Phone**
Cell Phone**
☐ Male ☐ Female
Email*
Parental/Volunteer Support:
Gender*
☐ Coach ☐ Manager
Player Information
☐ New Player
☐ Returning Player
First Name*
If returning, Ohio North Player ID Number:
Last Name*
M.I.
☐ Male ☐ Female
Gender*
☐ Recreational ☐ Competitive ☐ Premier ☐ TOPS
DOB (MM/DD/YYYY)*
Age Group*
Play Level*
Club*
League
Team ID Number
Shirt Size
Short Size
Sock Size
Emergency Contact #1*
Phone*
Emergency Contact #2
Phone
If applicable, list any medical problem(s)/physical limitation(s) the player has:
As a parent or legal guardian of the above named player, I request that the registrant’s name be removed from the Association’s magazine, camp, ODP, and other program mailing list. ☐
Ohio North Waiver
We, the registrant and the registrant’s legal parent or guardian, hereby agree and acknowledge the following: (1) We agree to abide by the rules of Ohio Youth Soccer Association
North (“Ohio North”) and its affiliated organizations and sponsors. (2) We recognize the inherent risk of serious or permanent physical injury and possible death associated with youth
soccer activities and games. In consideration for Ohio North accepting the youth player’s registration and participation in its sanctioned youth soccer leagues, tournaments and team
travel activities (“Youth Programs”), we hereby release, discharge and/or otherwise indemnify and hold harmless Ohio North, its affiliated organizations and sponsors, volunteers, their
employees and associated personnel, and the owners of fields and facilities utilized for the Youth Programs (“Releasees”), against any claim, lawsuit or written demand, including but not
limited to any claims for personal or physical injury disability, loss or damage to person or property, or death, whether arising from the negligence of the Releasees or otherwise to the
fullest extent permitted by law, by or on behalf of the registrant as a result of the registrant’s participation in the Youth Programs and/or being transported to or from the same, which
transportation we hereby authorize. (3) We authorize verification of the registrant’s date of birth from legal records to be provided to Ohio North authorized representative for the
limited purpose of verifying the Ohio North player’s age and identity. (4) We consent to emergency medical care prescribed by a duly licensed Health Care Provider or Dentist. This care
may be given under whatever conditions are necessary to preserve the life, limb or registrant’s well-being and we hereby agree to be financially responsible for all costs associated with
such treatment. (5) We consent to Ohio North taking photographs, video recordings, and/or sound recordings in documenting the activities of Ohio North’s programs and services. We
hereby grant Ohio North and their affiliates’ permission to use the negatives, prints, motion pictures, video/audio tapings, or any other reproduction of the same for Ohio North and its
affiliates’ educational and promotional purposes in manuals, on flyers, the internet, or other publications. (6) I understand that per Ohio “Return to Play Law” coaches and (or) referee
shall remove an athlete exhibiting signs, symptoms, or behaviors consistent with having sustained a concussion or head injury from practice or competition. Also, I understand that
coaches shall refrain from allowing an individual to return to the practice or competition from which the individual was removed, or to participate in any other practice or competition
until the individual has been assessed and cleared for return by a physician or by any other licensed health care provider authorized by youth sports organizations. WE HAVE READ THIS
RELEASE AND WAIVER OF LIABILITY AND FULLY UNDERSTAND ITS TERMS. WE UNDERSTAND THAT WE WAIVE SUBSTANTIAL RIGHTS BY SIGNING THIS FORM. WE AGREE TO WAIVE ALL
SUCH RIGHTS ABOVE INCLUDING THE RIGHT TO FILE A LEGAL ACTION OR ASSERT A CLAIM FOR PERSONAL OR PHYSICAL INJURY OR DEATH OF ANY KIND. WE SIGN THIS RELEASE FORM
FREELY OF OUR OWN FREE WILL.
Signature of Parent/Legal Guardian
Date
6650 W Snowville Rd, Ste Y, Brecksville, OH 44141
UPPER 90 FC
MEDICAL RELEASE FORM
As the parent/legal guardian of______________________________________________, I request that in my absence the
above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize
physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed
technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray
treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize
the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.
Date of Players Birth______ /________ /________ Date of last Tetanus Booster _______/__________ /__________
Known allergies of this player, including any allergies to medicine: _____________________________
___________________________________________________________________________________
Any other medical problems, which should be noted: ________________________________________
___________________________________________________________________________________
Family Physician: __________________________
Phone: _____________________________
Dentist: __________________________________
Phone: _____________________________
Preferred Hospital: __________________________________________________________________
Name of Parent/Guardian_____________________________________________________________
Address_____________________________________________________________________________
City___________________________
State__________________________
Zip _______________
Phone: (H) ________________________________ (W) ______________________________________
Person responsible for charges (if different from above)
Name: ____________________________________________________________________________
Address____________________________________________________________________________
City___________________________State_____________________________Zip _________________
Phone (H)______________________ (W) ______________________
Person to notify if parent/guardian is unavailable__________________________________________
Phone (H) _____________________________ (W) ________________________________
Insurance Carrier__________________________________ Policy Number ____________________
Signature of Parent/Guardian _________________________________________________________
STATE OF______________________ COUNTY OF_________________________
Sworn to and subscribed before me on the ______day of________________ 20___
Notary Public in and for the State of _________________ Commission expires_______________________
NOTARY SEAL
UPPER 90 FC
CODE OF CONDUCT- ATHLETE
As an athlete, I understand and accept the following responsibilities:
•
•
•
•
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I will respect the rights and beliefs of others and will treat others with courtesy and consideration.
I will be fully responsible for my own actions and the consequences of my actions.
I will respect the property of others. I will respect and obey the rules of my soccer club and laws of my community,
state and country.
I will show respect to those who are responsible for enforcing the rules of my soccer club and the laws of my
community, state and country.
I understand that as an athlete whose character or conduct violates UPPER 90 FC is not in good standing and is
ineligible for a period of time as determined by the club.
•
I hereby agree that if I fail to conform my conduct to the forgoing while attending, coaching, officiating or
participating in a sports event, I will be subject to disciplinary action, including but not limited to the
following in any order or combination:
•
•
•
Verbal and or written warning issued by an UPPER 90 FC official.
Suspension or immediate ejection from a sport event issued by an UPPER 90 FC official.
Season Suspension or multiple season suspensions issued by an UPPER 90 FC official.
_____________________________________
_____________________________________
YouthPlayerName(Print)
Date
_____________________________________
_____________________________________
SignatureofParent/LegalGuardian(Signature) Date
UPPER 90 FC
CODE OF CONDUCT- PARENT
Let the Coaches Coach: Your player is trying his/her hardest on the field and they hear many voices all at once. The most important
voice they need to hear is THEIR COACH’s voice. It becomes very confusing for your child while listening to YOUR voice, AND to the
voice of the coach. Coaching from the goal or either sideline is not acceptable.
Refrain from criticizing your child’s coach: Your child brings his/her best effort to their coach at every game. If the coach has been
undermined at home, it is easy for the player to lose respect and enthusiasm for the game and for their coach. If you have specific
concerns, please speak privately with the coach.
Please refrain from criticizing other players on your team OR on the other team. Ours kids are learning a team sport, which includes
GREAT sportsmanship on the part of parents and players to not only our team, but also the opposing team.
Referees. Referees are the easiest target for our anger and frustration. DO NOT CRITICIZE A REFEREE during a game. Sometimes
they make good calls, and sometimes they make bad calls. This is part of the sport. If you criticize the refs for how a game turns out,
you are teaching your child to blame someone else when things go wrong.
KEEP IT POSITIVE ON THE SIDELINE. Young players succeed best when they have both the support of their coach AND positive
encouragement of their parents. Young athletes do not need to be reminded of mistakes they made.
I therefore agree:
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I will teach my child that doing one’s best is more important than winning.
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I will refrain from ridiculing or yelling at my child or other participant for making a mistake or losing a competition.
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I will emphasize skill development and practices and how they benefit my child over winning.
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I will refrain from coaching my child or other players during games and practices.
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I will NOT engage in unsportsmanlike conduct with any coach, player, parent, participant, or official.
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I will NOT use drugs or alcohol while at a youth sports event.
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I will NOT engage in the use of profanity.
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I will treat any coach, parent, player, participant, official, or another attendee with respect regardless of race, creed, color,
national origin, ability, sex or sexual orientation.
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I will NOT engage in verbal or physical threats or abuse aimed at any coach, parent, player, participant, official.
I hereby agree that if I fail to conform my conduct to the forgoing while attending, coaching, officiating or participating in a
sports event, I will be subject to disciplinary action, including but not limited to the following in any order or combination:
•
•
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Verbal and or written warning issued by an UPPER 90 FC official.
Suspension or immediate ejection from a sport event issued by an UPPER 90 FC official.
Season Suspension or multiple season suspension issued by an UPPER 90 FC official
_____________________________________
_____________________________________
SignatureofParent/LegalGuardian(Signature) Date