Soccer Clip Boards
YOUTH PLAYER REGISTRATION APPLICATION
link to Word Document
PLAYER INFORMATION:
First Name _____________________________ Age _________
Last Name ______________________________ Birth Date _________
Gender (circle one) M – Male F – Female
New Player (circle one) yes no
PARENT/ GUARDIAN INFORMATION:
First & Last Name ___________________________________________
Street Address _____________________________________________
City State ZIP _____________________________________________
Phone _____________________________________________
E-mail ______________________________________________
EMERGENCY CONTACT INFORMATION
Emergency Contact (name, relation, phone) _____________________________________________________
If applicable, list any medical problems(s)/physical limitation(s) the player has: ________________________________
WAIVER
We, the registrant and the registrant’s legal parent or guardian, hereby agree and acknowledge the following: (1) We recognize the inherent risk of serious or permanent physical injury and possible death associated with youth soccer activities and games. In consideration for Coach Charles Lawrence accepting the youth player’s registration and participation in practices, we hereby release, discharge and/or otherwise indemnify and hold harmless Coach Charles Lawrence, his affiliated organizations and sponsors, volunteers, and associated personnel, including the owners of fields and facilities utilized for the practices, against any claim, lawsuit or written demand. (2) We consent to emergency medical care prescribed by a duly licensed Health Care Provider or Dentist. This care may be given under whatever conditions are necessary to preserve the registrant’s well-being and we hereby agree to be financially responsible for all costs associated with such treatment. (3) We consent to Coach Charles Lawrence taking photographs, video recordings, and/or sound recordings in documenting the soccer activities. We hereby grant Coach Charles Lawrence and his affiliates permission to use the negatives, prints, motion pictures, video/audio tapings, or any other reproduction of the same for educational and promotional purposes.
We have read this release and waiver of liability and fully understand its terms. We understand that we waive substantial rights by signing this form. We agree to waive all such rights above including the right to file a legal action or assert a claim for personal or physical injury or death of any kind. We sign this release form freely of our own free will.
Signature of Parent/Legal Guardian __________________________ Date ___________________
Office Use Only
Date Received ______ Birth Certificate ______ Payment Received _______ Cash/Check/Paypal ______