Medical and Waiver Form Fall 2015 – Spring 2016
MANHATTAN SOCCER CLUB PLAYER INFORMATION Last Name
First
Middle Initial Date of Birth Mo/Day/Yr City/State/Zip
Address: Number and Street Player Cell Phone
Sex M/F
Home Telephone School
Player E-Mail Address
P ARENT/GUARDIAN INFORMATION First
E-Mail Address
Address (if different): Number and Street
City/State/Zip
Home Phone (if different)
Employer
Cell Phone
Parent/Guardian 1 (Primary Contact)
Parent/Guardian 2
Last Name
Work Phone Last Name
First
E-Mail Address
Address (if different): Number and Street
City/State/Zip
Home Phone (if different)
Employer
Cell Phone
Work Phone
DOCTOR/EMERGENCY CONTACT INFORMATION Physician Name
Address
Telephone
Name of Alternative Emergency Contact (in case a parent cannot be reached in an emergency)
Cell
Insurance Company/Policy Number
Home
Please attach a photocopy of insurance card to this form
Work
MEDICAL CONDITIONS/LIMITATIONS/INJURIES/ALLERGIES/MEDICATIONS Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or other significant medical condition? Does this child take any regular medication?
YES If YES, please identify (attach additional page if needed) NO YES If YES, please state medication and reason NO
AUTHORIZATIONS: I hereby (i) authorize the coaches, managers, trainers, directors, employees or others acting as activity supervisors or vehicle drivers of Manhattan Soccer Club, Inc. and/or Manhattan Soccer Academy, Inc. (collectively, “MSC”) to act as my agent in connection with the Player’s participation in the activities of MSC, (ii) consent to medical, surgical or dental examination and/or treatment for the Player under whatever conditions are medically necessary and agree to pay the usual customary charges for such treatments or ambulatory care, (iii) authorize treatment and/or care of the Player at any medical facility or hospital and (iv) give permission for the Player to ride in a car, van, bus or other vehicle driven by a coach, manager, trainer, employee or other adult acting as activity supervisor or vehicle driver of MSC. WAIVER AND RELEASE OF LIABILITY: To induce MSC to permit the Player’s participation in the activities of MSC, I hereby agree to release, indemnify and hold harmless MSC, The City of New York, New York City’s Department of Parks and Recreation and their respective officials, directors, officers, employees, coaches, assistant coaches, trainers, independent contractors, sponsors, agents and representatives, from any claim, loss, liability, expense or damage arising out of injuries to the Player or to the Player’s personal property while participating the activities of MSC. I understand that this release applies to both future or present injuries, damages or loss and is binding on the Player and the Player’s heirs, executors and administrators. I understand that the Player may be photographed and/or videotaped during the activities of MSC and hereby grant MSC permission to use the Player’s likeness in photographs and/or video in any and all of its publications and in any and all other media. IMPORTANT INFORMATION: All players are bound by the By-Laws and Rules and Regulations of MSC. Copies of such rules are available from MSC at www.manhattansc.org. Registration with MSC is for one season (September 1, 2015 to August 31, 2016) as defined by the United States Youth Soccer Association (USYSA). Players are covered by MSC’s secondary accident and medical reimbursement insurance policies. By signing this document and registering the Player with MSC, you are indicating your agreement with the foregoing.
If Player is a minor: (Print name of minor’s parent or guardian)
(Date)
(Parent/Guardian Signature)
(Date)
(Player’s Signature)
If Player is NOT a minor: (Print name of Player)
KL2 2739745.1
