ST. CHARLES COUNTY YOUTH SOCCER ASSOCIATION (SCCYSA)
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* ASSN COACH *
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Team Number: Team Age: Team Gender:
HEAD COACHES NAME: Your Child's Name Your Child's Date of Birth (or age) |
First Name: MI: Last Name: Birth date: |
| Street Address: City: , MO Zip Code: |
| Phone: Work: Cell: |
| EMAIL ADDRESS: Gender: |
License Level: License Number: or SCCYSA Certificate Number: |
PLEASE READ ENTIRE AUTHORIZATION |
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. |
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SCCYSA COACHES MUST ABIDE BY THE FOLLOWING PRINCIPLES OF CONDUCT |
1. My first responsibility is the health and safety of all participants. |
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| I have read, understood, and agree to the Medical Treatment Authorization and the Principles of Conduct above:
When you click the Submit button, your Registration form is submitted to our office. |
YOU WILL AUTOMATICALLY BE DIRECTED TO BACKGROUND CHECK WHEN YOU HIT SUBMIT. EVERY ADULT WHO INTERACTS WITH THE CHILDREN MUST COMPLETE BACKGROUND CHECK AND RECEIVE AN ID BADGE FROM SCCYSA. |
