C HOME PHONE # ( _ _ _ ) _ _ _ - _ _ _ _ CELL


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TEAM

AGE GROUP U-

TRYOUT DATE

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PLAYER INFORMATION (PLEASE PRINT): FIRST NAME DATE OF BIRTH

LAST NAME /

/

CLUB/TEAM LAST SEASON

PLAYING EXPERIENCE/ NOTES : :

PARENT/GUARDIAN INFORMATION: PARENT/GUARDIAN #1 STREET ADDRESS CITY

ZIP CODE

HOME PHONE # ( _ _ _ ) _ _ _ - _ _ _ _ CELL PHONE # ( _ _ _ ) _ _ _ - _ _ _ _ EMAIL PARENT/GUARDIAN #2 STREET ADDRESS CITY

ZIP CODE

HOME PHONE # ( _ _ _ ) _ _ _ - _ _ _ _ CELL PHONE # ( _ _ _ ) _ _ _ - _ _ _ _ EMAIL EMERGENCY CONTACT INFORMATION: NAME

PHONE #

DOCTOR

PHONE #

ALLERGIES/MEDICAL CONDITIONS (PLEASE COMPLETE

BOTH SIDES)

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ABIDE BY RULES; CONSENT TO USE OF NAME AND LIKENESS I, the parent/legal guardian of the above-named player, a minor, or a player age 18 or over, (the “Player”), agree that I and the Player will abide by the rules and regulations of the U.S. Youth Soccer (USYS) and its affiliated organizations, US Club Soccer (US Club), the California Youth Soccer Association, Inc. (CYSA) San Carlos United , and the affiliated organizations of each of the foregoing (collectively, the “Soccer Organizations”) pertaining to the activities (the “Activities”) of the Soccer Organizations and the Player’s participation therein. I understand that any team (through its responsible officials, officers or representatives) that attempts to induce a registered player of any team under the jurisdiction of CYSA to leave his team before the end of the current year is deemed to have committed an offense for “poaching” in violation of CYSA Rules. If Player is a registered player of another CYSA team, I hereby certify that neither Player nor I were induced to try out and that I learned about San Carlos United Club’s tryouts through public notification and my own inquiries. I, for myself and the Player and our respective heirs, administrators and successors, grant the Soccer Organizations the right to use Player’s name, picture and/or likeness in or on printed, broadcast, website and other material concerning the Activities provided such use is related to the Player’s status as a participant in the Activities. RELEASE I, for myself and the Player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify USYS, US Club, CYSA, CCSL, San Carlos United, City of San Carlos, County of San Mateo, State of California, and the subdivisions of each of the foregoing, and all other organizations providing fields or facilities for activities (the “Activities”) of the Soccer Organizations, and the owners and operators of the field and/or facilities used for Activities, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in conjunction with the Player’s participation in any Activities including , without limitation, transportation to or from any Activity (which transportation is hereby authorized). CONSENT FOR MEDICAL TREATMENT (MINOR) I, for myself and the Player and our respective heirs, administrators and successors, hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine, Doctor of Osteopathy, Doctor of Dentistry, and emergency medical technician. This care may be given under whatever conditions are necessary to preserve the life, limb and well-being of the Player. Parent/Guardian Signature

Date

ACCEPTANCE REQUIRED TO COMPLETE PRE-REGISTRATION