Columbus TOPSoccer Club



[pic]

Columbus TopSoccer Club

PO Box 7366 Columbus, GA 31908 706-561-0561

Spring 2020 Registration Form

Please complete and bring with you to the first practice

Player’s Name:________________________________________________________________________

Address:_____________________________________________________________________________

Phone: (H) _____________________________________ Email:________________________________

Birth date:_____/___ /________ Age: _______________ Male______ Female_____

School:_____________________________________ Grade:______ Soccer Seasons Played:_______

Emergency Contact: ____________________________________Relationship: _____________________

Phone:________________________________

Additional Information Regarding Above Player

Please list any safety concerns we should know about:

Special Needs or Tips: PLEASE LIST ANY INFORMATION THAT THE COACHING STAFF NEEDS TO KNOW ABOUT YOUR CHILD TO FACILITATE A SUCCESSFUL SOCCER SEASON. CONTINUE ON THE BACK, IF NECESSARY.

Please circle YES or NO for the below:

Does your child use a picture schedule in school? YES / NO

Latex Allergy: YES / NO

Food Allergy: YES / NO if YES what type: _____________________

Insect Bite Allergy: YES / NO

Asthma: YES / NO

If your child has Asthma: do they use an inhaler YES / NO

Can they use inhaler independently YES / NO

Heart defect/heart disease/high blood pressure YES / NO

Diabetes YES / NO

Seizures/Epilepsy/Fainting Spells YES / NO if YES when was the last Seizure: ___________

Does your child have a Shunt YES / NO

Other Medical Concerns we should know about:

___________________________________________________________________________________________

(See other side, additional information & signature needed)

$15 Participation Fee:

Checks should be made payable to CYSC and

In the "for" section on the check:  place your child's name and also "TOPS Soccer"

T-Shirt Size (Please Circle):

Youth: Small Medium XLarge

Adult: Small Medium XLarge XXLarge

Release, Waiver of Liability, and Covenant Not to Sue

I hereby give approval for the participation of my child in any GSSA and affiliated associations of league activities and I assume all risk and hazards incident to such participation including transportation to and from said activities waive, release, absolve, indemnify and agree to hold harmless the GSSA and affiliated association league, the organizers, supervisors, officers, directors, participants and persons or parents supervising or transporting participants to and from such activities from any claims arising out of injury to my child. I understand that a player who registers with an affiliated league is bound to that league for the entire seasonal year unless a transfer is requested for extenuating circumstances.

I give my approval for my child to participate in TopSoccer at Columbus State University. I understand that participation involves risk and I agree to the inherent risk of property damage and personal injury, including injury that might prove fatal, that my child might sustain. In exchange for my child’s participation in TopSoccer, I release Columbus State University, the Board of Regents of the University System of Georgia, staff, and volunteers from all liability resulting from my child’s participation in TopSoccer and its activities. And "I acknowledge, and understand, that as a member institution of the University System of Georgia and its Board of Regents; Columbus State University is exempt from Georgia's Department of Early Care And Learning (DECAL) requirements."

Authorization to Use Image or Photograph

TopSoccer has frequent occasion to illustrate and explain its program and activities for volunteer recruitment, fund-raising, enhancing community awareness, news releases, brochures, reports, etc. Toward these efforts it is most beneficial to use photographs and/or video of our friends/participants. However, we would never intentionally offend our friends/supporters by doing these things without their understanding and consent. Should you feel comfortable in assisting us in this manner, we would appreciate your consent. I, as parent/guardian with legal responsibility for this participant, consent to TopSoccer using photographs and/or video of my son/daughter for such purposes as described above.

Parent/Guardian Information (Please Print):

Name: ________________________________ Cell:________________________

Signature: ________________________________ Date: _____________

................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download