Michigan State Developmental Soccer League

Affiliate of USYSA and MSYSA

PLAYER REGISTRATION FORM

Player First Name *

Player Last Name *

Date of Birth *

Street Address *

City *

State *

Phone Number *

Zip Code *

Previous Soccer Team Registered With: (Team Name + Season ex. Celtic 01 Black 2014-15

Team Information

I Voluntarily agree to play soccer for the: *

Affiliate Name *

Year * Year

Color *

Gender *

Boys

Girls

Your email address you want the completed form sent to: *

Enter Email

Confirm Your email address you want the completed form sent to: *

Confirm Email

of the Michigan State Developmental Soccer League. I understand that signing this form binds me to the above named club for the entier seasonal year (fall/spring) unless an application for transfer is granted by the above named club, MSDSL, and MSYSA

Signature of Player *

Clear

Date

Signature of Parent *

Clear

Date *

Liability

Michigan State Developmental Soccer League Athletic Waiver and Release of Liability

In consideration of being allowed to participate in any way in MSYSA sanctioned soccer activities, the undersinged:

1. Acknowledge and fully undersand that each participant will be engagin in activities that invovle risk of serious injury including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used, and acknowledge further, that there may be other risks not known or not reasonably foreseeable at this time;

2. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death.

3. Release, waive, discharge and covenant not to sue the MSYSA, its member Associations, affiliated clubs, or teams and their respective administrators, directors, agents, coaches, and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter, referred to as "Releases" from demands; losses or damages on account of injury, including death or damages to property, caused or alleged to be caused in whole or in part by the negligence of the "Release" or otherwise.

Printed Name of Parent/Guardian: *

Date *

Concussion (scroll to the bottom)

WHAT IS A CONCUSSION?

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by a bump, blow, or jolt to the head or body that causes the head and brain to move quickly back and forth. Even a “ding,” “getting your bell rung,” or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury. If an athlete reports one or more symptoms of concussion after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury. The athlete should only return to play with permission from a health care professional experienced in evaluating for concussion.

DID YOU KNOW?

• Most concussions occur without loss of consciousness.
• Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
• Young children and teens are more likely to get a concussion and take longer to recover than adults.

SYMPTOMS REPORTED BY ATHLETE:

• Headache or “pressure” in head
• Nausea or vomiting
• Balance problems or dizziness
• Double or blurry vision
• Sensitivity to light
• Sensitivity to noise
• Feeling sluggish, hazy, foggy, or groggy
• Concentration or memory problems
• Confusion
• Just not “feeling right” or is “feeling down”

SIGNS OBSERVED BY COACHING STAFF:

• Appears dazed or stunned
• Is confused about assignment or position
• Forgets an instruction
• Is unsure of game, score, or opponent
• Moves clumsily
• Answers questions slowly
• Loses consciousness (even briefly)
• Shows mood, behavior, or personality changes
• Can’t recall events prior to hit or fall
• Can’t recall events after hit or fall

“IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON”

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow, or jolt to the head or body s/he exhibits any of the following danger signs:

• One pupil larger than the other
• Is drowsy or cannot be awakened
• A headache that gets worse
• Weakness, numbness, or decreased coordination
• Repeated vomiting or nausea
• Slurred speech
• Convulsions or seizures
• Cannot recognize people or places
• Becomes increasingly confused, restless, or agitated
• Has unusual behavior
• Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

1. If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it’s OK to return to play.

2. Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, and playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

3. Remember: Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete’s brain is still healing, s/he is much
more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases,
repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

Date *

US Youth Soccer

PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

Father's Printed Name *

Father's Phone Number (Home/Cell) *

Mother's Printed Name *

Mother's Phone Number (Home/Cell) *

In an emergency, when parents cannot be reached, please contact:

Emergency Contact (1) Name: *

Emergency Contact (1) Home Phone: *

Emergency Contact (1) Work Phone: *

Emergency Contact (2) Name:

Emergency Contact (2) Home Phone:

Emergency Contact (2) Work Phone:

Allergies *

Other Medical Conditions: *

Player's Physician:

Physician Phone:

Medical and/or Hospital Insurance Company: *

Insurance Phone Number: *

Policy Holder: *

Policy # *

Group #: *

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

Recognizing the possibility of injury or illness, and in consideration for US Youth Soccer and members of US Youth Soccer accepting my son/daughter as a player in the soccer programs and activities of US Youth Soccer and its members (the "Programs"), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify US Youth Soccer, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of fields and facilities utilized for the Programs, against any claim by or on behalf of my player son/daughter as a result of my son's/daughter's participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination by a licensed medical doctor and has been found physically capable of participating in the sport of soccer. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child's participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

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DCFC Youth MSDSL

Michigan State Developmental Soccer League

PLAYER REGISTRATION FORM

Team Information

Liability

Michigan State Developmental Soccer League Athletic Waiver and Release of Liability

Concussion (scroll to the bottom)

WHAT IS A CONCUSSION?

WHAT ARE THE SIGNS AND SYMPTOMS OF CONCUSSION?

DID YOU KNOW?

SYMPTOMS REPORTED BY ATHLETE:

SIGNS OBSERVED BY COACHING STAFF:

“IT’S BETTER TO MISS ONE GAME THAN THE WHOLE SEASON”

CONCUSSION DANGER SIGNS

WHAT SHOULD YOU DO IF YOU THINK YOUR ATHLETE HAS A CONCUSSION?

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

JOIN THE CONVERSATION www.facebook.com/CDCHeadsUp

TO LEARN MORE GO TO >> WWW.CDC.GOV/CONCUSSION

US Youth Soccer

PARENT/GUARDIAN CONSENT AND PLAYER MEDICAL RELEASE FORM

PARENT/GUARDIAN CONSENT AND MEDICAL RELEASE

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