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TARPON FC
Competitive Tryout Registration
Player Name - First: _________________________ Last _________________________________
Player Birth - Month:______________ Day_______ Year________
Sex Female____ Male____
Club Played for Last Season________________________________________________________
- Age Group U9B U10B U11B U12B U13B U14B U15B U16B U17B U18B
U9G U10G U11G U12G U13G U14G U15G U16G U17G U18G
- Mailing Address__________________________________________________________________
City_______________________________________________ Zip______________________
Home Phone________________________________________
Mother’s Name________________________________________ Cell #__________________
Father’s Name_________________________________________ Cell #__________________
Primary E-mail__________________________________________________________________
Emergency Contact Name________________________________ Cell #__________________
Do you have a 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, name of insurance company) Policy # __________________________________________
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___
Parent/Guardian __________________________________ Date _______________________
CLICK HERE TO PRINT FORM
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