The information below is required for all Scottish United Soccer Club players. Team managers will be provided the database of information for their respective team, and a binder should be kept with the team medical kit.

Name

First Name

Last Name

Date of Birth

YYYY

Team to which the Player is Registered

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Email Address

Health Care Number

Supplementary Insurance (if applicable)

Message

Emergency Contact

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Family Physician

First Name

Last Name

Physician Phone Number

(###)

###

####

Allergies

Pre-Existing Illnesses / Conditions

Glasses / Contact Lenses?

Yes

Please Provide Any Other Relevant Information

Player Medical Information