Player’s Last Name,                   First Name                                   M.I.
.

Street                                                 City and State                                   Zip

Sex: M  or  F      Birth date: mm dd ,yyyy

Phone 1:      Phone 2:

Insurance Co: Policy #:

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 I become injured in any way during my participation in soccer events or activities associated with the Released Parties. I further state that I take full responsibility for any injury that may occur as a result of my participation, and that I will not hold the Released Parties responsible for any aggravation of preexisting injuries prior to or during my participation in any soccer events or activities associated with the Released Parties.

#1 Parent/Guardian:

#2 Parent/Guardian:

 E-Mail (ex: johnsmith@yahoo.com)

 Type your name:

Please print form sign form and date form, then turn it in.

__________________________________________________ Date: _______________