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.