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Fall 2011 Registration
I hereby consent to the Ross Valley Youth Soccer Club registering me with US Club Soccer. I understand that I may be registered to only one US Club Soccer member club at any time.
First Name*
Middle Initial
Last Name*
Email*
Phone with area code
Mailing Address*
City*
State*
Zip*
Birthdate Month-Day-Year*
Select
January
February
March
April
May
June
July
August
September
October
November
December
-
Select
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
-
Select
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
Gender*
Select
Male
Female
Level*
chart of birthdates for each level
Select
U10 Girls
U10 Boys
U12 Girls
U12 Boys
U14 Girls
U14 Boys
U19 Girls
U19 Boys
School
Grade in Fall `0
select
2**
3
4
5
6
7
8
9
10
11
12
** U10 players must be 8 by August 1, 2011 or in 3rd grade. Any exceptions must have approval from Jean Marc at Ross Recreation.
Positive Coaching Alliance
The Positive Coaching Alliance class for parents will be held in late August - date to be announced. For all players it is mandatory that at least one parent attend the Positive Coaching Alliance seminar unless you elect to pay an additional $25 non-participation fee.
select
Yes, I will attend the PCA class
No, I will not attend. I will pay the $25 fee
I have already attended.
Father's Name
Father's email
Father's phone
Mothers's Name
Mother's email
Mother's phone
Allergies
Other Medical Conditions
Emergency Contact*
Emergency Phone*
Emergency Doctor*
Doctor Phone*
Medical Insurance Company*
Insurance Phone*
Policy Holder's Name*
Policy Number*
Volunteer
The soccer season couldn't happen without all of our parent volunteers. Please let us know what areas you are available to help make the 2010 season a successful season for all our players.
select
$75 Buy Out
Coach/Assistant Coach
Field Lining
Game Day Support
MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER
I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify the club, US Club Soccer, their sponsors, the USSF and its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the soccer player named above as a result of that player's partic ipation in US Club Soccer programs and/or being transported to or from the same, which transportation I hereby authorize.
Name of person completing this form:
Relationship to player:
I HAVE READ THE ABOVE WAIVER AND RELEASE, AND CONSENT FOR MEDICAL TREATMENT.
By clicking here
I represent that I am the parent or guardian of the minor athlete being registered on this form for Ross Valley Youth Soccer Club and my click is my signature for this waiver and release and medical consent.
