Player: Playerfirstname Playerlastname

Email, phone: Phone, cell: Cellphone

BoyorGirl, Grade, born Month Day, Year

 

Mothername and Fathername

Physician: Physician, Physiciantelephone

Streetaddress, City, State  Zip

Emergency: Emergencycontact, Emergencyphone

Save a copy of this page as an HTML document on your computer. Check the info, then print THREE copies of this page. Sign and mail all three to Irvington AYSO. Save a fourth copy for your files. If registering two or more players, send all forms in a single envelope. Mail the signed forms, birth certificate, and a check for $65 made out to Irvington AYSO to Irvington AYSO, c/o Amy Zerman, 36 Butterwood East, Irvington, NY 10533. Read the following disclaimer and sign each form. Printing questions? Click here.

EMERGENCY AUTHORIZATION: I, the undersigned parent or legal guardian of the above player, a minor, hereby authorize the coaches, team parents, the above-identified Emergency Contact and/or other AYSO officials to act as my agents in the capacity of activity supervisors and vehicle drivers, and to consent to medical, surgical or dental examination and/or treatment.

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I, the undersigned parent or legal guardian of the above player, a minor, for myself and on behalf of the above player, our heirs, assigns and next of kin, acknowledge that participation in soccer necessarily involves travel, play in adverse field conditions, contact with considerable force, and risk of severe, permanent physical injury including bruises, scrapes, strained, sprained or torn muscles, tendons or ligaments, broken bones, dislocation of joints, concussion, brain damage, nerve and spinal cord injury, paralysis and death. For myself, and on behalf of the above player, our heirs, assigns and next of kin, we willingly and voluntarily accept and assume all such risk.

For myself and on behalf of the above player, I further acknowledge that the American Youth Soccer Organization ("AYSO") is primarily administered by volunteers rather than paid professionals. For myself and on behalf of the above player, he/she and I willingly and voluntarily agree to comply with the stated and customary terms and conditions for participation and, if he/she or I observe any unusual significant concern in his/her readiness for participation and/or in the program itself, I will remove him/her from participation and bring such concern to the attention of the nearest official immediately and also of the regional commissioner as soon as possible thereafter.

In consideration of accepting the registration and permitting the voluntary participation of the above-named participant in its programs, for myself and on behalf of the above player, our heirs, assigns and next of kin, I hereby release, discharge and agree to hold harmless AYSO, its employees, volunteers, officials, sponsors and other representatives and any and all owners, lessors, lessees or other persons or entities allowing, permitting or authorizing the use of facilities by AYSO and the agents, employees, officers and directors of said persons or entities from any and all claims, demands, costs expenses and compensation arising out of or in any way related to any injury or other damage that may result to said participant or to members of my family or my household or individuals I invite or for whom I am otherwise responsible while participating in or present at any AYSO-sponsored event, including any physical or other injury caused by the negligence of any person or entity described above.

ACKNOWLEDGEMENT AND CONSENT: I acknowledge receipt of the Soccer Accident Insurance pamphlet and I understand the terms of the Plan. For both internal and external use, I acknowledge that AYSO may compile and use addresses and soccer photographs of the named individual. I consent to such uses and hereby waive all rights to compensation.

I HAVE READ THE ABOVE EMERGENCY AUTHORIZATION, DISCLAIMER, ASSUMPTION OF RISK AND WAIVER, AND ACKNOWLEDGEMENT AND CONSENT AGREEMENTS, FULLY UNDERSTAND THE TERMS OF EACH, UNDERSTAND THAT I AND THE ABOVE PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT FOR MYSELF AND ON BEHALF OF THE ABOVE PLAYER.

Parent/Guardian Signature_____________________________________________Date _____________

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