Parent or Legal Guardian Information. Primary Guardian Relationship Address City State Zip Home Phone Cell Phone Email Employer Occupation Office Phone Secondary Guardian Relationship Address City State Zip Home Phone Cell Phone Email Employer Occupation Office Phone Emergency Contact Information Family Physician Emergency Phone Person to notify other than parent Home Phone Cell Phone As the parent or legal guardian of the above player, I request that in my absence the above named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic, treatment or operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken from the above named player. In addition, the above named player and I, as the parent or legal guardian of the above named player agree that I and the player will abide by the rules of the USYSA, its affiliate organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the player for its soccer programs and activities I hereby release, discharge and/or otherwise indemnify and hold harmless the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the programs and activities, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and activities and/or being transported to or from the same, which transportation I hereby authorize. I further acknowledge that this registration binds the player to the club for the seasonal year as provided for in KYSA rules. Fees owed to Louisville Soccer must be paid before any release or transfer can be approved. I hereby give Louisville Soccer permission to publish and use pictures of which I may be included in whole or in part. If the person photographed is under 18, I certify that I am his or her parent or legal guardian and I give my consent without reservation to the foregoing on his or her behalf to publish and use pictures on our website, in brochures, promotional materials or any other documents utilized to further the mission and go...
