MEMBERSHIP AND MEDICAL RELEASE FORM
Program Year: 2017
Program: Travel _______ House_______
Legal Authorization
Parent(s)/Guardian
Information
Player Medical Information
Player Information
P.O. Box 94 Akron, New York 14001
Last Name
First Name
MI
Birthdate
Address
City
State
Zip
Home Phone
Cell Phone
Gender
Email
Last Soccer Club/Team
Insurance Carrier
Policy #
Male __________ Female __________
# of Seasons Played
List Any Medical Problems
Emergency Contact
Relationship
Doctor's Name
Phone
Phone
Parent/Guardian #1
Phone
Cell Phone
Address
City, State, Zip
Relationship
Parent/Guardian #2
Phone
Cell Phone
Address
City, State, Zip
Relationship
As the parent/legal guardian of the above named player, 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 accept
full financial responsibility for any such treatment. I also give permission for any transportation required to a medical facility and assume full
financial responsibility for said transportation. Recognizing the possibility of injury associated with soccer and in consideration for the
USSF/USYSA and its affiliates accepting the registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise
indemnify the USSF/USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the
fields and facilities utilized for the Programs/Tournaments against any claim by or on behalf of the registrant as a result of the registrant’s
participation in the Programs/Tournaments and/or being transported to or from same, which transportation I hereby authorize. My
son/daughter has received a physical examination by a physician and has been found physically capable of participating in the
Programs/Tournaments.
I have read the information above and fully understand and accept responsibility as it is outlined.
Signature of Parent/Legal Guardian
Date
Youth
Adult
Volunteer/Parental Support
Uniform
XS
S
M
L
XL
XS
S
M
L
XL
Coach
Concessions
Reporter
Shirt
Asst. Coach
Field Preparation
Shorts
Team Manager
Clerical
Newsletter
Special
Projects
Team Parent
Publicity
Donor
Referee
Fundraising
Other
Tournament
Board Member
Socks
Jersey Number
CHOICE
1st
2nd
3rd
4th
Official Use Only
Registration/Transfer/
Change
Birthdate
Verified
Player Fee
Other Fee
Cash/Check
Picture Received
Received
by
Uniform Fee
Total Fees
Date
FORM 1001 (1/13)
Akron Soccer League, Inc.
Soccer Player/Parent Code of Conduct
Soccer is a competitive, contact sport and winning is an aspect of the game. It is far more important to promote:
FAIR PLAY and FUN while developing the basic skills and knowledge of the game. The ultimate goal of the league is to
have all players, parents, coaches and spectators keep this in the forefront of their minds as they participate in the game.
The REFEREE is the official on the field and as such can and will penalize players on or off the field of play for
breaches of the rules of the game. This includes fouls against other players and dissent, disrespect, or abuse of the
referee. Obscene language and profanity will not be allowed. The referee may also warn, caution or eject (with or without
previous warning) a player, coach, parent or spectator. The referee has that authority before, during and after the game.
The use of tobacco and alcohol at games and practices is strictly prohibited.
AS A SOCCER PLAYER, I promise to follow all the rules of the game, come to practices and games prepared,
abide by the referee’s decisions, and demonstrate good sportsmanship both on and off the field.
AS A SOCCER PARENT/SPECTATOR, I promise to enthusiastically support the players, to avoid coaching from
the sidelines, avoid negative criticism toward the coaches, other players, other parents and referees.
I, the undersigned parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules
of the USYSA (United States Youth Soccer Association) and its affiliated organizations and sponsors.
________________________________________
Player Name
________________________________________
Parent/Guardian Signature
____________
Date
Minor Photo Release Form
I give Akron Soccer League permission to publish in print, electronic, or video format the likeness or image of my child. I
release all claims against the League with respect to copyright ownership and publication including any claim for
compensation related to use of the materials.
MINOR’S NAME:
.
YOUR NAME
.
(Parent or Guardian, Please print)
YOUR SIGNATURE:
DATE:
.
General Guidelines: It is recommended that a release be obtained when photographing or videotaping a minor (under 18).
Parent or guardian signatures are required; signatures of minors are not sufficient. When images are published, ASL will
take cautionary steps to provide minimum identifying information and will not use specific street or mailing addresses, email addresses, or phone numbers.