INTERMEDIATE OPTION 1  SOCCER PROGRAM REGISTRATION 

 

Please fill out the form below completely. Print this page, sign, attach your check or money order (contact your coach for fees) and  COPY OF BIRTH CERTIFICATE  mail to: 

Pueblo Rangers Soccer Club

1530 w. 17th St.

Pueblo, CO. 81003

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Player Information:

Name: Birth Date:Uniform size:

Address:     City:       Zip Code:

Home Phone:    Cell/Work Phone:  

E-Mail:

Parent Information:

Father:Address:H Ph: W Ph:

E-Mail

Mother: Address:H Ph: W Ph:

E-Mail:

                               

IMPORTANT

I, the parent/guardian of the below-named player, a minor, agree that I and the player will abide by the rules and regulations of the USYSA, its affiliated organizations and its sponsors (“USYSA Parties”). In consideration of the player’s participation in the soccer programs and activities of the USYSA Parties (the “Programs”). I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player’s participation in the programs including, without limitation, players transportation to/from any Program, which transportation is hereby authorized. I further grant the USYSA Parties the right to use the player’s name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player’s status as a participant in the Programs.

 

Name ___________________________________________

                             Player (Please print)

Signature X _______________________________________ Date:______________

 

Name___________________________________________

                             Parent Guardian (Please Print)                                                                                                        

Signature X_______________________________________ Date: ______________

 

 CONSENT FOR MEDICAL TREATMENT (MINOR)

As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medical or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb and well-being of my dependent.

 

Signature of Parent or Guardian X_________________________________

Address_________________________________________

City_____________________________________ State____ Zip____________

Phone:   Home: (______)________- ______________________                           

Phone:   Business: (______)______-_______________________