Youth Soccer League Registration Form

Youth Soccer League Registration Form
Registration Deadline Sat. June 17 at 12noon
,KDYHUHDGXQGHUVWDQGDQGDJUHHWRWKHFDQFHOODWLRQUHIXQGWUDQVIHUSROLFLHV
&DVK$OOIRUPVUHFHLYHGDW%&&6%DUWOHWW5G%DUWOHWW,/
+HDG RI +RXVHKROGBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&KHFN0RQH\2UGHU,QSHUVRQGURSRIIPDLOLQ
&UHGLW&DUG)D[LQ&DOOVDPHGD\
WRYHULI\WKDWID[ZDVUHFHLYHG3OHDVHFRPSOHWHWKH
UHOHYDQWLQIRUPDWLRQORFDWHGEHORZ
$GGUHVV BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&LW\ BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB =LS BBBBBBBBBBBBBBBBB
(PDLO $GGUHVV BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&DUG7\SH
+RPH 3KRQH BBBBBBB BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&DUG 1XPEHUBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&HOO3KRQHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
&DUG+ROGHUÚV1DPHBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
$PHULFDQ([SUHVV
0DVWHUFDUG
9LVD
'LVFRYHU
([SLUDWLRQBBBBBBBBBBBBBBBBBBBBBBBBBBBBB&,'BBBBBBBBBBBBQXPEHUVRQEDFNRIFDUG
)DWKHUÚV 1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
$PRXQW &KDUJHG BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
0RWKHUÚV 1DPH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
$XWKRUL]HG 6LJQDWXUH BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Are you interested in volunteering for your child’s team? (circle)
3OHDVHOLVWDQ\PHGLFDWLRQVFXUUHQWO\EHLQJWDNHQRUGHVFULEHVSHFLDO
DFFRPPRGDWLRQVQHHGHGIRUVXFFHVVIXOLQFOXVLRQLQWRWKHSURJUDPV
Head Coach | Asst. Coach | Team Coordinator
Name of the person interested in coaching or coordinating*:
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
_____________________________________________________________________
*Volunteer Email (required):_________________________________________
BBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBBB
Participant's Last Name BBBBBBBBBBBBBBBBBBBBBBBB___________________________B BBBBBBBB
I understand that carpool, friendship, coach & practice locations cannot
be honored. __________,QLWLDOUHTXLUHG
Participant
Gender
Birthdate
Grade
Uniform Size: YM YL AS AL AXL
Program Name
ID Number
5HJLVWUDWLRQ%URFKXUH:DLYHU5HOHDVH
IMPORTANT INFORMATION
7KH%DUWOHWW3DUN'LVWULFWLVFRPPLWWHGWRFRQGXFWLQJLWVUHFUHDWLRQSURJUDPVDQGDFWLYLWLHVLQDVDIHPDQQHUDQG
KROGVWKHVDIHW\RISDUWLFLSDQWVLQKLJKUHJDUG7KH%DUWOHWW3DUN'LVWULFWFRQWLQXDOO\VWULYHVWRUHGXFHVXFKULVNVDQG
LQVLVWVWKDWDOOSDUWLFLSDQWVIROORZVDIHW\UXOHVDQGLQVWUXFWLRQVWKDWDUHGHVLJQHGWRSURWHFWWKHSDUWLFLSDQWVÚVDIHW\
+RZHYHUSDUWLFLSDQWVDQGSDUHQWVJXDUGLDQVRIPLQRUVUHJLVWHULQJIRUWKHEHORZOLVWHGSURJUDPVDFWLYLWLHVPXVW
UHFRJQL]HWKDWWKHUHLVDQLQKHUHQWULVNRILQMXU\ZKHQFKRRVLQJWRSDUWLFLSDWHLQUHFUHDWLRQDODFWLYLWLHVSURJUDPV
<RXDUHVROHO\UHVSRQVLEOHIRUGHWHUPLQLQJLI\RXRU\RXUPLQRUFKLOGZDUGDUHSK\VLFDOO\÷WDQGRUVNLOOHGIRUWKH
DFWLYLWLHVFRQWHPSODWHGE\WKLVDJUHHPHQW,WLVDOZD\VDGYLVDEOHHVSHFLDOO\LIWKHSDUWLFLSDQWLVSUHJQDQWGLVDEOHGLQDQ\
ZD\RUUHFHQWO\VXIIHUHGDQLOOQHVVLQMXU\RULPSDLUPHQWWRFRQVXOWDSK\VLFLDQEHIRUHXQGHUWDNLQJDQ\SK\VLFDODFWLYLW\
WARNING OF RISK
5HFUHDWLRQDODFWLYLWLHVDUHLQWHQGHGWRFKDOOHQJHDQGHQJDJHWKHSK\VLFDOPHQWDODQGHPRWLRQDOUHVRXUFHVRIHDFK
SDUWLFLSDQW'HVSLWHFDUHIXODQGSURSHUSUHSDUDWLRQLQVWUXFWLRQPHGLFDODGYLFHFRQGLWLRQLQJDQGHTXLSPHQWWKHUH
LVVWLOODULVNRIVHULRXVLQMXU\ZKHQSDUWLFLSDWLQJLQDQ\UHFUHDWLRQDODFWLYLW\8QGHUVWDQGDEO\QRWDOOKD]DUGVDQG
GDQJHUVFDQEHIRUHVHHQ'HSHQGLQJRQWKHSDUWLFXODUDFWLYLW\SDUWLFLSDQWVPXVWXQGHUVWDQGWKDWFHUWDLQULVNV
GDQJHUVDQGLQMXULHVGXHWRLQFOHPHQWZHDWKHUVOLSDQGIDOOVSRRUVNLOOOHYHORUFRQGLWLRQLQJFDUHOHVVQHVVKRUVHSOD\
XQVSRUWVPDQOLNHFRQGXFWSUHPLVHVGHIHFWVLQDGHTXDWHRUGHIHFWLYHHTXLSPHQWLQDGHTXDWHVXSHUYLVLRQLQVWUXFWLRQ
RURI÷FLDWLQJDQGDOORWKHUFLUFXPVWDQFHVLQKHUHQWWRLQGRRUDQGRXWGRRUUHFUHDWLRQDODFWLYLWLHVH[LVW,QWKLVUHJDUGLW
PXVWEHUHFRJQL]HGWKDWLWLVLPSRVVLEOHIRUWKH%DUWOHWW3DUN'LVWULFWWRJXDUDQWHHDEVROXWHVDIHW\
WAIVER AND RELEASE OF ALL CLAIMS AND ASSUMPTION OF RISK
3OHDVHUHDGWKLVIRUPFDUHIXOO\DQGEHDZDUHWKDWLQVLJQLQJXSDQGSDUWLFLSDWLQJLQWKLVSURJUDPDFWLYLW\\RXZLOOEH
H[SUHVVO\DVVXPLQJWKHULVNDQGOHJDOOLDELOLW\DQGZDLYLQJDQGUHOHDVLQJDOOFODLPVIRULQMXULHVGDPDJHVRUORVVZKLFK
\RXRU\RXUPLQRUFKLOGZDUGPLJKWVXVWDLQDVDUHVXOWRISDUWLFLSDWLQJLQDQ\DQGDOODFWLYLWLHVFRQQHFWHGZLWKDQG
DVVRFLDWHGZLWKWKHVHSURJUDPVLQFOXGLQJWUDQVSRUWDWLRQVHUYLFHVDQGYHKLFOHRSHUDWLRQVZKHQSURYLGHG
,UHFRJQL]HDQGDFNQRZOHGJHWKDWWKHUHDUHFHUWDLQULVNVRISK\VLFDOLQMXU\WRSDUWLFLSDQWVLQWKHVHSURJUDPVDQG
,YROXQWDULO\DJUHHWRDVVXPHWKHIXOOULVNRIDQ\DQGDOOLQMXULHVGDPDJHVRUORVVUHJDUGOHVVRIVHYHULW\WKDWP\
PLQRUFKLOGZDUGRU,PD\VXVWDLQDVDUHVXOWRIVDLGSDUWLFLSDWLRQ,IXUWKHUDJUHHWRZDLYHDQGUHOLQTXLVKDOOFODLPV
,RUP\PLQRUFKLOGZDUGPD\KDYHRUDFFUXHWRPHRUP\FKLOGZDUGDVDUHVXOWRISDUWLFLSDWLQJLQWKHVHSURJUDPV
DJDLQVWWKH%DUWOHWW3DUN'LVWULFWLQFOXGLQJLWVRI÷FLDOVDJHQWVYROXQWHHUVDQGHPSOR\HHV
,KDYHUHDGDQGIXOO\XQGHUVWDQGWKHDERYH
LPSRUWDQWLQIRUPDWLRQZDUQLQJRIULVN
DVVXPSWLRQRIULVNDQGZDLYHUDQGUHOHDVH
RIDOOFODLPV,IUHJLVWHULQJRQOLQHRUYLD
ID[P\RQOLQHRUIDFVLPLOHVLJQDWXUHVKDOO
VXEVWLWXWHIRUDQGKDYHWKHVDPHOHJDO
HIIHFWDVDQRULJLQDOIRUPVLJQDWXUH
3DUWLFLSDQWÚV1DPH
'DWH
3DUWLFLSDQWÚV6LJQDWXUH\HDUVRUROGHURU3DUHQW*XDUGLDQ
3$57,&,3$7,21:,//%('(1,(',IWKHVLJQDWXUHRIDGXOWSDUWLFLSDQWRUSDUHQWJXDUGLDQDQGGDWHDUHQRWRQWKLVZDLYHU
REGISTER TODAY AT WWW.BARTLETTPARKS.ORG or 630-540-4800