Player's First Name: ____________ MI: ___ Last:___________________________

Current Age: ________      Date of Birth: Month____ Day____Year_______

Home Street Address: __________________________________Apt:______

City _____________________   State: CA      Zip Code: ___________

Home Phone: (_____)____________________

Your email address(es): home:_________________________work: _________________________

Years in AYSO _____ Years in club soccer (if any): ___

Positions played best:___________________________________________

Does/has he/she play(ed) goalkeeper? ______

Did he/she play on a club team (e.g., CYSA) last year? (  ) no  (  ) yes 

Father’s name: __________________________________________________

Father’s address (if different) ________________________________

Father’s work phone: (_____)__________________ ext: ______

Mother’s name: _________________________________________________

Mother’s address (if different) ________________________________

Mother’s work phone: (_____)__________________ ext: ______

Current medical conditions/prohibitions:_______________________________

Allergies (food, insect bite, medicine):_______________________________

Medication taken on a regular basis:_____________________________

Person to contact in an emergency:

Name: _____________________ Phone Number: (_____)__________________

Doctor to contact in an emergency:

Name: _____________________ Phone Number: (_____)__________________

Emergency hospital preferred: __________________________________

Name of medical insurance company:_______________________________

Medical insurance policy number: ________________________________

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Names of Buddies that you would like to be paired with: ___________________________

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Credit card information (if not paying by check or online)

Authorization to Charge Credit Card
Name on card  
Card number     Expiration
CVV [Last 3 digits from back of Visa and MC]
Billing address: Street City State Zip
Daytime phone number, with area code   
Email address
CVV [Last 3 digits from back of Visa and MC; 4 digits from front of Amex]

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LIABILITY RELEASE
TALENT RELEASE
MEDICAL TREATMENT AUTHORIZATION FOR A MINOR

1. My child, ___________________________, has my permission to participate in try-outs, camps, practices, scrimmages, games, indoor soccer, parties, field trips, and other activities, including travel to and from, hereafter known as “functions”, that may be scheduled from time to time by SAYSO.

2. My child is in good health and is able to participate in these functions.

3. I understand that soccer is a strenuous physical sport, can be dangerous, and there is an inherent risk of injury. My child will use protective equipment (e.g., soccer boots, shin guards, eye protection, padded goalkeeper equipment, etc.) or, if she doesn’t, she does so at her own risk and with my permission.

4. While my child is participating in these functions, I HEREBY AUTHORIZE THE ADULT COACHING STAFF, or in their absence, any accompanying or assisting adult, TO ADMINISTER ANY EMERGENCY FIRST AID OR MEDICAL ATTENTION “ON THE SPOT,” AND TO CONSENT TO TREATMENTS FOR MY CHILD, including but not limited to, any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment, and hospital care which is advised by, and is to be rendered under the general or special supervision of, any physician, surgeon, or dentist, AND, I AGREE TO PAY FOR SAME.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. This authorization shall remain effective indefinitely, until my child no longer plays with SAYSO. A SIGNED PHOTOCOPY OF THIS AUTHORIZATION IS AS VALID AS THE ORIGINAL.

5. I understand that try-outs and some other functions may not be covered by any insurance, and that I AM SOLELY RESPONSIBLE for the cost of any service or treatment provided. After registering with SAYSO, I will be responsible for the cost of any treatment provided which is not covered by insurance.

6. I HEREBY RELEASE AND HOLD HARMLESS the San Andreas Youth Soccer Association, the team’s regular, guest, and volunteer coaching staff, parental helpers and assistants, team members and their families, referees and other game officials, and the city of the function from against any suits, claims, charges, demands, losses, damages, and expenses incurred from any and all illnesses and injuries incurred, regardless of cause or severity, that may befall my child during functions. I understand that it is not possible to recognize or correct every dangerous condition or physical field hazard or to anticipate every injurious event, and I RELEASE AND HOLD HARMLESS the individuals and organizations listed in this paragraph from those responsibilities. These releases and these authorizations remain valid indefinitely, can only be changed or revoked in writing, and then, only when signed by SAYSO.

7. I am the parent or legal guardian of the listed child and am authorized to sign this agreement. I will keep SAYSO informed about any changes in the status of parent/legal guardianship for my child.

8. The information I have provided to SAYSO is true, accurate, and complete. No verbal promises of any nature contradicting this agreement and release have been made, can be made, or ever will be made to me. Legal fees and other costs shall be awarded to the prevailing party in arbitrated or legal disputes.

9. Any photographs or videos taken of my child may be used for promotional and commercial purposes.

 

Signature of Parent/Legal Guardian:_____________________________Date:____________