Age: U-7 U-8 U-9 U-10 U-11 U-12 U-13 U-14 U-15 U-16 U-17 U-18 Gender: Male Female
Date of Birth	Month: January February March April May June July August September October November December Day: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year: 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004

Last Name
First Name
Street Address
City
State	Select State Alabama Arkansas Alaska Arizona California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming
Zip Code
Contact Email
School name
Grade	1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th
Father/Guardian Name
Father Home Phone
Father Cell Phone
Father Work Phone
Father E-mail
Mother/Guardian Name
Mother Home Phone
Mother Work Phone
Mother 's Cell Phone
Mother/Guardian Email
In Emergency, Contact Name
Home Phone
Work Phone
Cell Phone
Doctor to Notify (name)
Doctor Phone #
Medical Insurance: Company
Policy Number
Medical Info (known Allergies)
Players Soccer Experience
Player's Social Security Number or Club's ID#

MEDICAL RELEASE

(1).  I hereby give my permission for my child to participate in the activities of the Sports Youth America Soccer Club (SYASC). I understand that soccer is a potentially dangerous sport with the possibility of injury to my child, and I acknowledge that it is my responsibility to provide any insurance and to pay for treatment for any injury to my child while participating in SYASC activities. I will not hold the directors, coaches or SYASC liable for any injury that might occur while my child is participating in SYASC sanctioned games or activities. I certify that my child has been examined by physician within the past year and has been found to be physically fit to participate in the SYASC soccer program. I hereby give my permission for any and all medical attention necessary to be administered to my child in the event of any accident, injury, illness, etc., until such time as I may be contacted. I assume all responsibility for payment of any such medical treatment that may be necessary.

PUBLICITY RELEASE

(2)  Permission is hereby granted to SYASC to use the voice/audio recordings, photographs, videos and the name of my child for public relation purposes, including media coverage of the Club's events and activities and advertising that may include brochures, posters, print, radio, TV or electronic media. I hereby waive any right to compensation, fee or royalty for myself, the participant/player or our successors, heirs or assigns in connection with the production or use of the aforesaid materials.

COMMITMENT

(3)  I have read the above and, if my child is selected to a SYA team, I am prepared to make a good faith effort to respect my and my child's commitment to that team for at least two seasons (Spring/Fall or Fall/Spring)

 

Parent/Guardian Digital Signature
Date	mm/dd/yyyy