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		COMPETITIVE TRYOUT FORM

	*All Fields Require Data To Be Entered*


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First Name
Last Name
Date of Birth
Age Group
Club's Played
Mailing Address
City
State
Zip
Home Phone
Email Address
Mother's Name
Mother's Cell #
Father's Name
Father's Cell #
Primary E-Mail
Emergency Contact
Contact Phone #
Medical Info		Please note any pertinent medical information or problems:
Insurance Notice		All injuries must be reported within 90 days 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? SELECT > YES / NO IF YES, name of insurance company >
Policy Number
Informed Consent		I acknowledge that I am completely aware of the inherent risks associated with soccer. I 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 anyway during his/her participation in soccer events or activities associated with the RELEASED PARTIES. ENTER YOUR CONSENT BELOW: YES OR NO
Consent ?
Today's Date
Comment		Additional Comments:


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