PLAYER INFORMATION:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female

WHAT CLUB DID YOUR ATHLETE PLAY FOR LAST YEAR?

PARENTS CONTACT INFORMATION:

Fathers First Name
Fathers Last Name
Mothers First Name
Mothers Last Name
Primary Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Father Work Phone
Father Home Phone
Father Cell Phone
Father E-mail
Mother Work Phone
Mother Home Phone
Mother Cell Phone
Mother E-mail

DO YOU HAVE A CURRENT TARPON SPRINGS REC CARD?

Yes
No

MEDICAL INFORMATION - - Please note any pertinent medical information or problems::

INSURANCE NOTICE:  All injuries must be reported within 90 days of the date of injury. Benefits will be provided for eligible expenses not paid by other insurance health plans after the FYSA deductible has been satisfied.

Do you have other medical/dental insurance?

Yes
No

IF YES:

INFORMED CONSENT: I acknowledge that I am completely aware of the inherent risks associated with soccer, and hereby waive, release, and discharge the state association (FYSA) and all of its affiliated organizations, as well as their officers, directors, employees and agents (collectively, the “Released Parties”) from any and all liability and responsibility in the event that my child becomes injured in any way during his/her participation in soccer events or activities associated with the Released Parties.

I Do Consent:

Yes
No

Parental/Guardian Signature.

Date.