Sol Soccer Academy_Registration by stariya


									                                     Sol Soccer Academy
                                          2011-12 Registration

Age Group: __________                Date of Birth: __________                    Gender: _________

First Name: ___________________________ Last Name: ____________________________

Address: ______________________________________________________________________

City: ______________________________________ State: ______ Zip: __________________

Mother’s Name: _______________________________________ Cell: ____________________

Mother’s E-mail Address: _________________________________________________________

Father’s Name: _________________________________________ Cell: ___________________

Father’s E-mail Address: _________________________________________________________

Emergency Contact Name: ________________________________ Cell: ___________________

Physician Name: ________________________________________ Cell: ___________________

Allergies: ______________________________________________________________________

Other Medical Conditions: ________________________________________________________

Medical Insurance Company: _______________________________ Phone: ________________

Policy Holder: __________________________________ Policy Number: _________________


I, as the adult-age player or the parent/guardian of the registered, minor player, agree to abide by the rules
of Sol Soccer Academy and its affiliated organizations and sponsors. Recognizing the possibility of
physical injury associated with soccer and in consideration for Sol Soccer Academy accepting the
player for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify Sol
Soccer Academy, US Youth Soccer and 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 program and/or
being transported to or from the same, which transportation I hereby authorize. As the adult player or
parent/legal guardian of a minor participant in Sol Soccer Academy, I hereby give my 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 the player.
I certify that my child has been cleared a medical doctor to participate in the described sports program.

I understand that this registration constitutes a commitment for the 2011-12 year beginning in August, 2011
and ending July 2012. Training opportunities will be offered throughout the year for all age groups.

Adult Player or Legal Guardian of Minor Player (Print): _________________________ Date:________

Signature: _______________________________________

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