BU Boys' Soccer Fall 2022 Registration, Medical Consent, and Liability Waiver

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* 1. Player Info

Player's Name

Grade in School Fall 2022

Age as of July 4, 2022

Date of Birth

Player's Email Address

Player's Cell Phone Number

Player's Jersey Size

Player's Soccer Short Size

Returning Players Only: What is your jersey number?

Returning Players Only: Do you wish to keep your current jersey number?

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* 2. Have you submitted or do you plan to submit a Letter of Intent to your local school board for the 2022/2023 school year?

Yes

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* 3. Parent Info

Parents' Names

Mother's Email Address

Father's Email Address

Mother's Cell Phone Number

Father's Cell Phone Number

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* 4. Address Information

Street Address?

City, State and Zip Code?

Area of town for carpooling purposes?

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* 5. Are you willing to share your contact information with our team's current players and their parents?

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* 6. Medical Information and Emergency Treatment Consent

Insurance Company

Primary Insurance Holder's Name

Primary Insurance Holder's Date of Birth

Policy ID Number

Group Number

Primary Physician's Name

Primary Physician's Phone Number

Important Medical Information

Emergency Contact (other than parents) Name

Emergency Contact Phone Number

Relationship of Emergency Contact to Athlete

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* 7. I authorize Bluegrass United Boys' Soccer coaches, administrators, and/or parent volunteers to act as my agent in the event I am not able to be reached in an emergency situation. I consent to any emergency medical treatment deemed necessary by a medical professional.

By digitally signing this document you are agreeing with these authorizations.

Yes, I give my consent.

No, I do not give my consent.

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* 8. I have read, understand, and agree to follow all expectations and rules as outlined in the BU Boys' Soccer Fall 2022 Expectations Document.

I understand that participating families enter into a voluntary association with BU and BU Boys' Soccer when they join the BU Boys' Soccer Team. This relationship remains until such time that either party decides the relationship is no longer beneficial to the student and/or BU Boys' Soccer.

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* 9. I understand that soccer is a contact sport and physical injury is possible. I agree that I will not hold any person associated with Bluegrass United responsible for any injury my child may incur.

COVID-19/VIRUS WARNING AND WAIVER ADDENDUM

Due to the inherent risk of exposure to COVID-19 and/or other virus strains while at a soccer game and/or practice , it is important that you diligently follow all posted instructions, written rules,
and generally accepted health recommendations and precautions per CDC and state health guidelines and directives concerning the spread of any and all viruses. Viruses may be extremely contagious and can lead to severe illness and death. You should always assume that
anyone could have a Virus on the Premises. (Premises is defined as any physical place such as practice field, game field, any facility, home, or any place associated in any way with this team.)

There is no representation or warranty that:
1- Any Premises is currently or will remain free of Viruses,
2- persons on the Premises are not carrying Viruses or
3- exposure to Viruses cannot occur on the Premises.

While on the Premises:
1 - You must exercise due care for your safety at all times.
2 - You agree to take full responsibility for and voluntarily assume all risks related to exposure to Viruses.
3 - You agree to release, indemnify, discharge, and hold coaches, managers, other players, those holding any and all positions associated with the management of the team, all representatives, and all who are associated with the team at any and all Premises harmless to the fullest extent allowed by law for all present and future claims and liabilities relating to Viruses, including but not limited to any negligent act or
omission by management, which might occur as a result of your being on the Premises.

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* 10. Player Confirmation

Player's Signature (by typing your name, you are digitally signing this document)

Date

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* 11. Parent Confirmation

Parent's Signature (by typing your name, you are digitally signing this document)

Date

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* 12. Medical Information and Emergency Treatment Consent

Insurance Company

Primary Insurance Holder's Name

Primary Insurance Holder's Date of Birth

Policy ID Number

Group Number

Primary Physician's Name

Primary Physician's Phone Number

Important Medical Information

Emergency Contact (other than parents) Name

Emergency Contact Phone Number

Relationship of Emergency Contact to Athlete