Portneuf Valley Soccer Club

PVSC SPRING 2010

 

Circle Age/Level for “Club” soccer tryouts/sign-ups:

 

U13      U14      U15      U16      U17      U18                  Sex:      Male     Female

 

I desire to Play-up from age                  

 

Last Name                                            First Name                                Middle Initial                

 

Address                                                                        City                              Zip      

 

Name of School                                                                             Grade                     

 

Last Team                                                        Date of Last Season                             

 

Birth Date                                           Age                  Phone                                                             

 

Parent/Guardian                                                                        Day/Work Phone                                 

 

Address (If different)                                                                Night/Home Phone                               

 

Parent E-mail Address:___________________________________________________________

 

List any medical problems, allergies or prohibitions                                                          

 

                                                                                                                                             .

 

Person to notify in emergency (except parent/guardian)                                                   Phone              

 

Doctor to notify in emergency                                                    Phone                                      

 

Primary Insurance                                                      Group/Policy Number                        

 

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the GCYSL; its affiliated organizations and sponsors.  Recognizing the possibility of physical injury associated with soccer and in consideration for the GCYSL accepting the registrant for its soccer programs and activities  I hereby release, discharge and/or otherwise indemnify the GCYSL, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the GCYSL events, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the GCYSL activities and/or being transported to or from the same, which transportation I hereby authorize.

 

As the parent or legal guardian of the above-named player, I hereby give 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 my dependent.

 

 

Signature of Parent or Guardian

 

                                                                                                Date