Playdate Registration
June 2022
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Player Name *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Grade in Fall 2022 *
School *
Parent/Guardian Name *
Parent/Guardian Phone/Cell Number *
Parent/Guardian Email *
Emergency Contact Name *
Emergency Contact Phone Number *
List medial problems or player limitations:
Current Team Name
Current Level
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Season *
Release of Liability:  I, the parent/guardian of the registrant(s), a minor, agree that the registrant and I will abide by the rules of the USYSA (United States Youth Soccer Association), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge, and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportations I hereby authorize. *
Consent for Medical Treatment (Minor(S)):  As the parent or legal guardian of the above-named player(s), I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of my dependent. This release shall remain in effect for the duration of the seasonal year and shall be interpreted under WI law. *
Playdates Attending (select all that apply) *
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