Cedar Valley Soccer Club
Cedar Valley Soccer Club Player Registration Form Last name (as appears on birth certificate)
First Name (as appears on birth certificate)
Middle Initial
Address
City, State
Zip Code
( ) Telephone
Contact E-mail
Assigned School/Grade Birthdate (MM/DD/Year)Male/Female Mother’s Birthdate (DD/MM) ------------------------------------------------------------------------------------------------------------------------------------------------Father’s Last Name
Father’s First Name
Address (if different from above)
Mother’s Last Name
City, State Zip
Mother’s First Name
Address (if different from above)
City, State, Zip
( ) ( ) ( ) ( ) Home Phone Cell Phone Home Phone Cell Phone --------------------------------------------------------------------------------------------------------------------------------------------------( ) ( ) Person to Notify in case of Emergency Phone Number Doctor Phone Number ---------------------------------------------------------------------------------------------------------------------------------------------------Parental Support – as a volunteer organization, we ask for active participation of at least one Parent in our program: Father
Mother
1.Coach/Asst. Coach 2. Referee 3. Fields - set up/teardown 4. Comm. Board 5. Fields - maintenance 6. Team Sponsor 7. Concessions 8. $125 Donation ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Team Shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large
---------------------------------------------------------------------------------------------------------------------------------------------------Consent for Medical Treatment (Minor) I, the parent or legal guardian of the above named player, do hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I, the Parent/guardian verify that the above information is correct. I understand than any misrepresentation of data will result in disqualification and/or disciplinary action. I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of USYSA, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer programs and activities (“the Programs”), I hereby release, discharge, and/or otherwise indemnify the USYSA, its affiliated members and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on the behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to/from the same, which transportation I hereby authorize.
Name of Parent/Legal Guardian (please print)
Signature
Date
Cedar Valley Soccer Club - PO Box 391 - Cedar Falls, IA 50613 www.cedarvalleysoccerclub.org
First Name (as appears on birth certificate)
Middle Initial
Address
City, State
Zip Code
( ) Telephone
Contact E-mail
Assigned School/Grade Birthdate (MM/DD/Year)Male/Female Mother’s Birthdate (DD/MM) ------------------------------------------------------------------------------------------------------------------------------------------------Father’s Last Name
Father’s First Name
Address (if different from above)
Mother’s Last Name
City, State Zip
Mother’s First Name
Address (if different from above)
City, State, Zip
( ) ( ) ( ) ( ) Home Phone Cell Phone Home Phone Cell Phone --------------------------------------------------------------------------------------------------------------------------------------------------( ) ( ) Person to Notify in case of Emergency Phone Number Doctor Phone Number ---------------------------------------------------------------------------------------------------------------------------------------------------Parental Support – as a volunteer organization, we ask for active participation of at least one Parent in our program: Father
Mother
1.Coach/Asst. Coach 2. Referee 3. Fields - set up/teardown 4. Comm. Board 5. Fields - maintenance 6. Team Sponsor 7. Concessions 8. $125 Donation ----------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Team Shirt Size Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large
---------------------------------------------------------------------------------------------------------------------------------------------------Consent for Medical Treatment (Minor) I, the parent or legal guardian of the above named player, do hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I, the Parent/guardian verify that the above information is correct. I understand than any misrepresentation of data will result in disqualification and/or disciplinary action. I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of USYSA, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer programs and activities (“the Programs”), I hereby release, discharge, and/or otherwise indemnify the USYSA, its affiliated members and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on the behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to/from the same, which transportation I hereby authorize.
Name of Parent/Legal Guardian (please print)
Signature
Date
Cedar Valley Soccer Club - PO Box 391 - Cedar Falls, IA 50613 www.cedarvalleysoccerclub.org
