ADULT PLAYER REGISTRATION FORM                             

 Complete, print, mail this form to PO Box 1868, Carolina Beach, NC 28428. Include check/money order for $80 to "PISA".

League Name 

PISA Adult Soccer League

Club Name 

PISA Soccer Association

Team Name

City

State

NC

 I hereby consent to the above-named club registering me with US Club Soccer.  [Note: it will not be necessary to complete this form again as long as I am with the same club or team unless the information below changes. 

                                                                                                                         //

Player’s Signature                                                                                               Date ______________________________________________________________________________________________

PLAYER’S  INFORMATION 

First Name

Last

Birth Date: //

Street:

City:

NC

Zip:

Home Phone: --

Cell Phone:--

Bus. Phone:--

Driver’s Lic. #:

State:

Email: @ .

 

Please list any Allergies:

Please list any other medical conditions: 

 In an emergency, please contact the following:

Name

Home Phone:

--

Cell Phone:

--

LIABILITY  WAIVER, RELEASE, AND INDEMNIFICATION AGREEMENT

 I recognize the possibility of physical injury associated with soccer, and voluntarily accept and assume this risk as part of my playing soccer for the above-named soccer organization.

 I hereby release, discharge, and otherwise indemnify my club and team, US Club Soccer, their sponsors, the USSF and its affiliated organizations, the soccer facility, and the employees and associated personnel of these organizations, against any claim by or on my behalf, as a result of my participation in US Club Soccer programs and competitions.

 I understand that my organization has chosen to cover me with optional secondary accident medical insurance, but the coverage is not effective until a medical roster with player information has been submitted to US Club Soccer, and the insurance premium has been paid.  I understand I am also covered with the same liability insurance coverage afforded all other members of, and players and staff registered with, US Club Soccer.

 

    Player’s Signature:____________________________________                   Date // 

Mail completed form & $80 check/money order payable to "PISA". PO Box 1868, Carolina Beach, NC 28428. Final Deadline is Jan. 29