Soccer Clip Boards
link to Word Document


First Name  _____________________________        Age  _________

Last Name  ______________________________        Birth Date  _________

Gender (circle one)              M – Male          F – Female
New Player (circle one)               yes          no


First & Last Name ___________________________________________

Street Address  _____________________________________________

City   State   ZIP  _____________________________________________

Phone  _____________________________________________

E-mail  ______________________________________________


Emergency Contact (name, relation, phone)  _____________________________________________________

If applicable, list any medical problems(s)/physical limitation(s) the player has:  ________________________________

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  ______