Player’s Name ________________________Age _______DOB____/____/____Grade__________

Gender _________________ Current Level of Play ___________________________________

Parent/ Guardian ______________________________ Email _____________________________

Address___________________________City_________________State_________Zip________

Home phone  ________________________Work _______________ Cell_____________________

Emergency Contact ____________________________Phone____________________________

Signature of Parent Guardian _________________________Date_________________________

Parent Guardian: The SUSA participant is in good health and has my permission to participate in soccer
training activity. I am aware of the risks associated with my son’s/ daughter’s involvement in soccer and
related activities. In the event of an emergency, I hereby give permission to SUSA staff, directors and
physician selected by the SUSA directors to secure proper treatment for the camper. I will be fully r
esponsible for all medical expenses incurred by my child while attending the program. I give permission f
or SUSA to use my child’s image in future advertising and promotional materials.