Kingman Soccer Club AWS
FOR OFFICIAL USE ONLY- 17 /18 Season
Kingman Soccer Club P.O. Box 4122 Kingman, AZ 86402
AGE Verified
www.kingmansoccerclub.com Registration Fees, a copy of the Player’s State Certified Birth Certificate if new player, Parent Code of Conduct and Head Injury Notification Forms are due at time of Registration. Late fees will apply if registering after the regularly scheduled registration dates.
PLEASE PRINT
Player’s Last Name
Player’s First Name
Mailing Address
MI
City
Home/Cell Phone Number
State
Zip
_E-mail
Age
Birth Date
Has your child played competative soccer in the past? Yes
/
No
/_
Male
Female
How many years have they played competitive soccer?___
How did you hear about us? School Flyer _____ Newspaper_____ Radio____ Website ____ Facebook ____ Email from us____ other ______________________ Does your child play another sport during the competitive season? No _____ Yes _____ What Sport? ______________________________________________ Does this player have a brother or sister who would also be interested in playing completive soccer? Yes If yes, please list the sibling here: Name
No Birth Year __
Father’s Name
Cell Phone
Mother’s Name
Cell Phone
Legal Guardian
Cell Phone
(If other than parent)
NOTES: _________________________________________________________________________________________________ ________________________________________________________________________________________________________ CONSENT FOR MEDICAL TREATMENT (MINOR) As the parent or legal guardian of the above named player, I 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. It is understood that I, as the parent or legal guardian, am financially responsible for all medical treatment of the above named player. Person to Notify in an Emergency
Relationship
Phone
Other than parent
Doctor to Notify in an Emergency
Phone
List any medical conditions or restrictions for this player The undersigned parent/guardian of the above recorded minor does hereby authorize the officer, leader, or coach, as agent(s) of Kingman Youth Soccer League (KYSL) to transport as required the above minor to and from association sponsored activities, including, but not limited to, athletic and social events. I, the parent/guardian of the registrant, agree that the registrant and I will abide by the rules of KYSL, its affiliated organizations and sponsors. Recognizing the possibility of injury associated with soccer and in consideration for the KYSL accepting the registrant for its soccer program and activities (the Programs), I hereby release, discharge and/or otherwise indemnify the KYSL, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and /or being transported to or from the same, which transportation I hereby authorize. I further grant the KYSL Parties the right to use the player’s name, picture and/or likeness in printed, broadcast and other material concerning the programs provided such use is related to the player’s status as a participant of the programs and understand that financial compensation will not be provided for use of participant’s image by KYSL. KYSL confers no rights of ownership whatsoever. I further agree that as the parent/guardian or child KYSL will be entering my information into League Management software, Contact Management software and website software used by KYSL. I release KYSL, its contractors, volunteers, and board members from liability claims by me or any third party in connection with participation of the child in any KYSL programs. I also acknowledge that I have read the parent / player code of conduct and concussion forms and agree to the terms within them. Due to many factors unfortunately no refunds can be offered.
Name
Signature X
Date
Please Print Name of Parent/Guardian CLUB/LEAGUE OFFICIAL USE ONLY
PARENTAL SUPPORT: Your Help is appreciated!! Circle area(s) in which you would be willing to help. Coach
Asst. Coach
Manager
Amount paid: $
Cash
Board Member
Posting News
Team Parent
Date:
Check #
Fundraising
Team Events
Team Photos
Received by:
M.O. #
The player may be terminated if the check written for registration fees is returned due to insufficient funds. The player will be reinstated when the $35.00 fee for returned checks is paid in addition to the original amount of the check. Cash or money orders will be the only acceptable payment methods for these fees. Refunds must be requested in writing. Refund requests will not be accepted after the draft has taken place. The Board will review refund requests on a case-by-case basis and reserves the right to approve/disapprove refunds on a case-by-case basis. Refunds will not be given when a player has decided not to play after registering. Proof of injury or proof of relocation may be required when requesting a refund due to an injury that will preclude the player from playing for the rest of the season, or a move that will require the player to reside out of the Kingman area. WHITE – REGISTRAR COPY
PINK – PARENT COPY
Kingman Soccer Club P.O. Box 4122 Kingman, AZ 86402
AGE Verified
www.kingmansoccerclub.com Registration Fees, a copy of the Player’s State Certified Birth Certificate if new player, Parent Code of Conduct and Head Injury Notification Forms are due at time of Registration. Late fees will apply if registering after the regularly scheduled registration dates.
PLEASE PRINT
Player’s Last Name
Player’s First Name
Mailing Address
MI
City
Home/Cell Phone Number
State
Zip
_E-mail
Age
Birth Date
Has your child played competative soccer in the past? Yes
/
No
/_
Male
Female
How many years have they played competitive soccer?___
How did you hear about us? School Flyer _____ Newspaper_____ Radio____ Website ____ Facebook ____ Email from us____ other ______________________ Does your child play another sport during the competitive season? No _____ Yes _____ What Sport? ______________________________________________ Does this player have a brother or sister who would also be interested in playing completive soccer? Yes If yes, please list the sibling here: Name
No Birth Year __
Father’s Name
Cell Phone
Mother’s Name
Cell Phone
Legal Guardian
Cell Phone
(If other than parent)
NOTES: _________________________________________________________________________________________________ ________________________________________________________________________________________________________ CONSENT FOR MEDICAL TREATMENT (MINOR) As the parent or legal guardian of the above named player, I 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. It is understood that I, as the parent or legal guardian, am financially responsible for all medical treatment of the above named player. Person to Notify in an Emergency
Relationship
Phone
Other than parent
Doctor to Notify in an Emergency
Phone
List any medical conditions or restrictions for this player The undersigned parent/guardian of the above recorded minor does hereby authorize the officer, leader, or coach, as agent(s) of Kingman Youth Soccer League (KYSL) to transport as required the above minor to and from association sponsored activities, including, but not limited to, athletic and social events. I, the parent/guardian of the registrant, agree that the registrant and I will abide by the rules of KYSL, its affiliated organizations and sponsors. Recognizing the possibility of injury associated with soccer and in consideration for the KYSL accepting the registrant for its soccer program and activities (the Programs), I hereby release, discharge and/or otherwise indemnify the KYSL, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the Programs and /or being transported to or from the same, which transportation I hereby authorize. I further grant the KYSL Parties the right to use the player’s name, picture and/or likeness in printed, broadcast and other material concerning the programs provided such use is related to the player’s status as a participant of the programs and understand that financial compensation will not be provided for use of participant’s image by KYSL. KYSL confers no rights of ownership whatsoever. I further agree that as the parent/guardian or child KYSL will be entering my information into League Management software, Contact Management software and website software used by KYSL. I release KYSL, its contractors, volunteers, and board members from liability claims by me or any third party in connection with participation of the child in any KYSL programs. I also acknowledge that I have read the parent / player code of conduct and concussion forms and agree to the terms within them. Due to many factors unfortunately no refunds can be offered.
Name
Signature X
Date
Please Print Name of Parent/Guardian CLUB/LEAGUE OFFICIAL USE ONLY
PARENTAL SUPPORT: Your Help is appreciated!! Circle area(s) in which you would be willing to help. Coach
Asst. Coach
Manager
Amount paid: $
Cash
Board Member
Posting News
Team Parent
Date:
Check #
Fundraising
Team Events
Team Photos
Received by:
M.O. #
The player may be terminated if the check written for registration fees is returned due to insufficient funds. The player will be reinstated when the $35.00 fee for returned checks is paid in addition to the original amount of the check. Cash or money orders will be the only acceptable payment methods for these fees. Refunds must be requested in writing. Refund requests will not be accepted after the draft has taken place. The Board will review refund requests on a case-by-case basis and reserves the right to approve/disapprove refunds on a case-by-case basis. Refunds will not be given when a player has decided not to play after registering. Proof of injury or proof of relocation may be required when requesting a refund due to an injury that will preclude the player from playing for the rest of the season, or a move that will require the player to reside out of the Kingman area. WHITE – REGISTRAR COPY
PINK – PARENT COPY
