YOUTH :: REGISTRATION FORM
(Player's Under 18 Years of Age)

ALL PLAYERS WILL BE REQUIRED TO HAVE A COMPLETED REGISTRATION FORM PRIOR TO PARTICIPATION.

NO REGISTRATION WILL BE CONSIDERED COMPLETE UNTIL THE RECEIPT OF THIS REGISTRATION FORM
AND THE RECEIPT OF FULL PAYMENT.

REGISTRATION INFORMATION
Note that fields marked with an * are required.
 PLAYER INFORMATION
* First Name
Nickname (if any)
* Last Name
* Sex
* Age Group
* Date of Birth (mm/dd/yyyy) select

 PARENT / GUARDIAN INFORMATION
* Relationship to Player If other, please specify:
Salutation
* First Name
* Last Name
* Mailing Address
* City
* State
* Zip Code
* Email Address
* Primary Phone Number  Please include your area code
* Primary Phone Number is ? If other, please specify:
Alternate Phone Number  Please include your area code
Alternate Phone Number is ? If other, please specify:

 PLAYER'S MEDICAL / PERSONAL INFORMATION
* I hereby certify that the above named Player is in good health and is able to participate in all activities, and any medical deficiencies have been noted below. If any attention is required for illness or injury, I give my consent to have an athletic trainer, medical doctor, nurse, hospital or clinic provide the above named Player with medical assistance and or treatment, and agree to be responsible financially for the cost of such assistance and or treatment.
* Name of Medical Insurance
  Company
* Group / Policy Number
Are there any special or
  pre-existing medical conditions
  we should be aware of ?
List any medical allergies or
  other pertinent medical
  information.
* Emergency Contact Name
* Primary Emergency Contact
  Phone Number		  Please include your area code
* Primary Emergency Phone
  Number is ?		 If other, please specify:
  Alternate Emergency Contact
  Phone Number		  Please include your area code
  Alternate Emergency Phone
  Number is ?		 If other, please specify:
* Emergency Contact's relationship
  to Player		 If other, please specify:
List any other forms of contact
  or persons to contact in an
  Emergency situation.

 PARTICIPATION WAIVER
* As parent or legal guardian of the above named Player, you must read this waiver form. Submission of this form signifies that they have read, understand and abide by the information contained in this form.

There are risks associated with the participation in the above named program and its related activities. You release and hold harmless El Paso Patriots Soccer Club, and any and all of its affiliates, corporate sponsors, players, coaches, owners, directors, employees, and volunteers, from all action, suits, and demands and costs whatsoever in law including reasonable attorneys fees and costs or equity including but not limited to the risk of injuries from participating in any program associated with El Paso Patriots Soccer Club, and any and all of its affiliates, corporate sponsors, players, coaches, owners, directors, employees, volunteers, and to the risk of loss of personal property by theft or otherwise.

By submitting this form you acknowledge that you have read and understands that you and the above named Player are giving up substantial rights by submitting this form and that you submit this form voluntarily.
* Full name of person providing
  this Waiver
* Relationship of person providing
  Waiver to Player		 If other, please specify:
* Date of Waiver select
 
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