Have you registered for the Porterville Soccer or Futsal Leagues before?

NEW PLAYER'S INFORMATION

*First name:

*Last name:

*Birth date:

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*Gender:

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*Mailing Address:

*City:

*State:

*Zip Code:

Uniform size (Jersey, shorts):

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PARENT/GUARDIAN 1 INFORMATION

*Parent Name:

*Home phone:

LEAGUE UPDATES CONTACT INFORMATION If applicable, provide an email or a cell phone where texts can ben sent for league updates, game time change or cancellations, etc.

Email:

Cell phone:

EMERGENCY/MEDICAL INFORMATION

*Emergency Contact Name 1:

*Emergency Contact Phone 1:

Emergency Contact Name 2:

Emergency Contact Phone 2:

List of allergies player has:

List of other medical conditions:

Physician Name:

Physician Phone:

Medical Insurance Company:

Medical Insurance Co Phone:

Policy Holder Name:

Policy No:

REQUEST PLACEMENT

Request to be on team with:

MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify the club, US Club Soccer, their sponsors, the USSF and its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the soccer player named above as a result of that player’s participation in US Club Soccer programs and/or being transported to or from the same, which transportation I hereby authorize.

*Parent Initials: *Date:

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To complete registration you must pay event fees with credit card thru Paypal ($5.00 fee will be added to cover credit card service if paying by PayPal) or send check with appropriate fees payable to 'South Valley Chivas Academy' at:

PORTERVILLE FUTSAL LEAGUE
1430 W WESTFIELD AVE
PORTERVILLE,CA. 93257

BY CHECKING THIS I ACCEPT ALL TERMS