Brecksville Soccer Organization Get In The Game
Home  
US Youth Soccer Player Membership Form
BRECKSVILLE SOCCER ORGANIZATION
Player Information
* indicates required field
* First Name:   * Last Name:
  Initial:
* Birth Date: mm/dd/yyyy  * Gender:
* Jersey:
* Height:   ft.   in. * Weight: lb.
* Shorts:
* Address:
  Age Group Tryout:
* City: * State:
* Zip:
 Recent Club / City
Team Played on:		   Recent Workshops or
Training Camps Attended:
Potential extracurricular activities conflict:
  
Parent Information 
* Parent Name: Phone: * (h) (000-000-000) (w) (000-000-000) (c) (000-000-000)
* Parent Name: Phone: *(h) (000-000-000) (w) (000-000-000) (c) (000-000-000)
* Primary E-mail:
  Secondary E-mail:
* Emergency Contact Name (non-parent):  * Relationship:
  Phone: *(h) (000-000-000) (w) (000-000-000) (c) (000-000-000)
*Does your child have any allergies or other conditions we should be aware of? Yes No
If yes, please describe:
* Family Physician: * Phone: (000-000-000)
 

WAIVER OF LIABILITY:
I, the parent/guardian for the above child release, discharge and/or otherwise indemnify the organization/league/club for which I am registering the child to play, Brecksville Soccer Organization, its affiliated sponsors, employees and associated personnel, including the owners of fields and facilities utilized against any claim by or on behalf of the registrant as a result of his or her participation.

GENERAL CONSENT FOR MEDICAL TREATMENT:
I hereby give my consent to have a coach, athletic trainer, emergency personnel and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment.

PLAYER AND PARENT CODE OF CONDUCT:
Both the player and parent agree to abide by the Brecksville Soccer Organization Code of Conduct posted on our website under the Registration section. Violation of either will result in immediate dismal from the organization without refund.

 
By clicking "SUBMIT", I confirm that all of the above information is accurate and that I understand and agree to all terms and conditions.