Player Information:
Last Name:____________________________________________________________
First Name:____________________________________________________________
Home Phone:__________________________________________________________
Mailing address:________________________________________________________
Player e-mail:__________________________________________________________
Date of birth:___________________________________________________________
Current Travel Club:_____________________________________________________
# of Seasons:___________________________________________________________
Positions played:_______________________________________________________
Parent’s Information:____________________________________________________
Mother’s Name:________________________________________________________
Mother’s Home Phone ___________________________________________________
Mother’s Cell Phone:____________________________________________________
Mother’s Email address:_________________________________________________
Father’s Name :________________________________________________________
Father’s Home Phone:___________________________________________________
Father’s Cell Phone:____________________________________________________
Father’s Email address:__________________________________________________
Person to Notify in Emergency :___________________________________________
Phone number:_________________________________________________________
Doctor’s name:________________________________________________________
Medical Consent & General Liability Release
I, the parent/guardian of the player named hereon, acknowledge that participation in the sport of soccer, as in any sport, may result in injury. The undersigned parent-guardian therefore waives, releases, discharges and/or otherwise indemnify the White Plains Youth
Soccer Association , its member clubs, leagues, teams, players, agents, officers, coaches, administrators, volunteers, sponsors and contractors and associated personnel, including the owners of fields and facilities utilized for the program, from all liability or responsibility for any claim damage or legal action on behalf of the player or the player’s parents, heirs, or personal representatives arising from an injury the player may sustain while participating in soccer or related activities, including these tryouts and transportation. I hereby give my consent to have an athletic trainer, emergency personnel, and/or doctor of medicine or dentistry provide my dependent with such medical assistance and/or treatment (including without limitation first aid, medical, dental, surgical, diagnostic or hospital procedures) as may be necessary. I understand that the White Plains Youth Soccer Association does not carry medical insurance for players participating in tryouts, practices, friendly scrimmages and other WPYS sponsored activities and that I am responsible for the player’s insurance coverage until the player is officially registered as a player with White Plains Youth Soccer .
___________________________________________________
Parent/Guardian Signature Parent/Guardian Printed Name Date