5tufu DUNEDIN STIRLING SOCCER CLUB

DUNEDIN STIRLING SOCCER CLUB
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2U6-2A17 GYSA (FALL)
REG'STRHTION FORM
PLEASE PRINT LEGIBLY
PLAYERNAME
AGE As
DATE OF BIRTH
BOY[
|
GrRLI
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]
ADDRESS
ZIPCODE
STATE
PARENT/GUARDIAN NAME(S)
HOME PHONE
ALT. PHONE
EMAIL ADDRESS (PLEASE PRINT LEGIBLY)
ARE YOU INTER.ESTED IN COACIilNG?
() YES 0
NO
PLAYERINF'O:
0NEYERPLAYED O PLAYED l -2 SEASONS OPLAYED3+
POSITIONS PLAYED
( )GOALTE ( )FORWARD (
REGISTRATION
F'EES:
)MTDFTELD
(
)DEFENSE
(
SEASONS
)NOSPECTF'TCPOSTTTON
U-6: $ 75 + g5g Volunteer fee
U-8: $95 + $50 volunteer fee
U-10 thru U-19 players: $135 + $50 volunteer
fee
VOLUNTEER OPPORTUNITIES:
I
UNDERSTAND TTIAT TIIIS IS A VOLUNTEER ORGANIZATION AND WOULD BE WILLING
HELP OUT IN TIIE FOLLOWING AREAS
0 CONCESSIONS 0 F'IELD MARSIIALL 0 MARKETING O OTHER:
**THE VOLWTEER FEE IS RETURNED ONCE 2 VOLWTEER HOARS ARE COMPLETED
FORTHE CLUB.
***** For Offlce
Age Grp:
Paid By:
In Gotsoccer:
Amount Pd:
Use Only
****
Accepted By:
Check/Conf#:
ry
Dundin Stlrling &ccer
Club
lMlcal
Release Forn
(Parent/Guardian) hereby give permission for any
I,
(Child's
and all medical attention to be administered to my
name) in the event of acqident, injury, sickness, etc., undir the direction of the person(s) listed below, until sush time as I may Ul contacted. t also assumc the responsibility for the paypent of any
such treatment,
shild
.
Parent(s) Name
Add"ress
City
zip
State
Code
Alt. Phone
Home Phone
-
Insurance Carrier
Subscriber
Group #
Policy #
behalf:
In case I oannot be reashed, any of the following persons is designated to act on my
Coach, assistant coach or team rnanager
Any league or tournament representative whore my child is playing
o
o
Child's Physician
Physician Address
Known allergies
Phone #
Date
Siguature of ParenUGuafdian
State of Florida, County
the-
On this
personally appearcd
of
daY
public, the yndelig:t-*,T:tt'
, before rne a notary
t tow, to me (or satisfactorilY
of
i::i'.1iil;:tfi:
[.i,ti'!ilt",; t'ff;r,n for the
strument. and acknowredeed that
conuined'
Purpgses therein
WITNESS mY hand and official seal'
Signature of Notary Public
Both parentdguardians and players are advised to take the Center for Disease Conhol's free online
concussion
faining HERE.
Under Florida law, this player who has suspected concussion or head injury must be removed from play
or practice. Before the player may r€turn to practice or competition a written medical clearance to rehrn
stating that the youth atlrlete no longer exhibits signs, symptoms, or be*raviors consistent with a
coticusion or other head injury must be received fiom an appropriue health care professional tained in
the diagnosis, evaluation, and management of concussions. In Florida, an appropriate health+are
professional (AHCP) is defined as either a licensed physician (MD, as per Chapter 458, Florida Statutes),
a licensed osteopathic physician (DO, as per Chapter 459, Florida Statutes), a licensed physicians
assistaat under the supervision of a MD/DO (as per Chapters 458.347 arrd 459.U22, Florida Statutes) or
health care professional trained in the management on concussions.
I have read and understand this consent fonrL and I volunteer to participate.
Player Name
Signature
Date:
As a parent or guardiarq I have rcad and understand this consent form and I give permission for my child,
namcd above, to participate.
ParenUlegal Guardian Name
Signaturc
Date:
DI]NEDIN PARIiS & RECREd,.TION DEPARTMENT
RELEASE, WATVER AND TNDEMNTTIUTTON
for myself, my heirs and personal
and his/her heirs
representatives, and for the minor child,
and personal representatives, hereby assume for myself and for said child, all liabilities, risks of loss, property
damage, injuries, including death, and hazards incidental to participation in all activities and programs offered
by the City of Dunedin Parla and Recreation Departnent or other sponsoring organization in which I, or said
child, particrpate(s), includiug transportation to or from the activity or program. I represent that I am the
natural parent or legal guardian of said child and have firll lawful authority to execute this release, waiver and
indemnification on behalf of said child, binding myself and said child and the c.hild's heirs and personal
representatives to the undertakings herein set forth. I am aware of, and acknowledge, the fact that this activity
or program may involve phlaical contact or other inherent risks where injuries may occur. I do hereby waive,
release and agree to indemuifr and hold harmless the CIIY OF DUNEDIN, its ofEcers, agents, employees, the
organizers, sponsors, activity superisors, and co-sponsoring organipli6ns for and from any claim, demand,
liability, costs, suits, drarges or compensation for loss, damage, injury of any kind, or death , including losses or
injuries arising from the negligence of the CITY OF DUNEDIN, its officers, agents, employees, sponsors,
organizers, or activity supenrisors, that may occur as a result of my, or said child's, participation in, or
presence at, the activity or progftlm. I assume all risk of injury, liability, and loss arising from the child's
participation in or presence at said activity. I acknowledge that the CITY OF DIINEDIN will not assume any
costs relating to any injtrry while the child is invotved in this activity.
This waiver, release and indemnification is in consideration of the CffY OF DUNEDIN or activity sponsor
permitting my, or said child's, participation in the activity or program and in furttrer consideration of the CITY
OF DUNEDIN not requiring seH-funded liability insurance coverage as a condition precedent to my, or said
child's, participation in the activity or program. I freely and voluntarily assume for myseH and for the said
child all risk of loss or injury arising from the child's participation in the activity whether due to the child's
negligence, or the negligence of others. I acknowledge that, absent this release and indemnification, the CIIY
OF DITNEDIN or other sponsor of the activity or program would not have offered me, or said child, access to
the activity or program because of unacceptable exposure to liability claims.
I have read this Release,
Waiver and Indemnification form in its entirety and understand the terms and
conditions it contains and sign it freely and voluntarily, and understanding that I waive legal rights to which I
and the child might otherwise be entifled if the child is hurt or suffers loss during the child's participation in
the activity. I represent and warrant that I have fulI legal authority to execute this form for the purposes
expressed herein as natural parent or legal guardian of the minor child.
This Release, Waiver and Indemnification form shall remain in firll force and effect for a]l activities or
prograrns until such time as the undersigned withdraws this Release, Waiver and Indemnification form in
writing and delivers same to the City of Dunedin Parla and Recreation Departrnent.
r
o
o
YOU MUST CAREFULLY READ THIS DOCLJMEI.IT BEFORE SIGNING
YOU ARE WAIVING OR RELEASING VALUABLE LEGAL RIGHTS.
ft.
YOU ARE ADVISED TO SEEK THE ADVICE OF AN ATTORNEY
T,JNDERSTAND THIS DOCUMENT.
SIGNED THIS
DAYOF
(Parent/Legal Guardian ifunder 18 years old)
Signed in the presence of the following witresses:
l,D. - r/16
GeneralWaiver
20
IF YOU DO NOT
FT]LLY
UNIFORM ORDEROLEASE CHECK SELECT ONLY ONE)
YOUTHSIZES:
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UNIFORMS:
UNIFORMS ARE THE PARENTS RESPONSIBILITY AND ARE ORDERE,D ON LINE USING
ADMIRAL OUR UNIF'ORM \rENDOR THE UNIFORM COST IS $45 AND INCLUDES A COMPLETE
GAME KIT AND A TRAINING JERSEY. YOU CAN PURCIIASE THE UNTFORM BY FOLLOWING
THE LINK ON OUR WEBSITE. PARENTS MUST ORDER THE PLAYERS UNIFOR}I BY NO LATER
THAN SEPTEMBER 23'd - @gn3nurc).