2015 Adult Outdoor League Registration
2015 Adult Outdoor League Registration Registration Deadline: June 1, 2015 Team Price: $65/player Player Name: __________________________________________ Birth Date: _______________ Parent / Guardian Name: _________________________________________________________ Address: ______________________________________________________________________ Preferred Contact Number: _______________________________________________________ Information below is used for team communications such as practices, travel and lodging. Enter contact info for team manager. Player email address & texting number: _____________________________________________ Other contact info: ______________________________________________________________ Mother’s Birthdate (month & day) _____________ needed to assign player registration number & for NDSA insurance Eligibility and Waiver Form As a legal adult or parent and legal guardian of ___________________________, I hereby consent medical care prescribed by a licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb and well-being on me or my dependent. We further acknowledge that the registrant and I will abide by the rules of US Youth Soccer (USYS), its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS accepting the registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify the USYS, its affiliated organizations and sponsors, their employees and associated personnel, including the owner of the fields and facilities for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and/or being transported to or from the same, which transportation I hereby authorize. Signed: ______________________________________________________ Insurance Co. ____________________ Date:______________________________ Minot Soccer Use: Fees paid & date: ______________________ Player ID #: ___________________________ MSA Adult Outdoor League Roster June 17 – July 24 Optimist Soccer Complex Registration Deadline: June 1, 2015 Team Price: $65/player Ages 16 and up – Max 14 players per team Team Name:_______________________________ Team Contact ______________________________ Phone Number____________________ E-mail______________________________________________ Release of Liability: I, being the Player or Guardian of the player listed beside my signature, hereby give approval to his/her participation in league activities including playing on the team listed on this sheet. I clearly understand this is NOT a US Youth Soccer sanctioned league. I recognize the possibility of serious injury to such player and assume all risks and hazards related to such league participation. I hereby release, discharge, absolve; and indemnify and agree to defend and hold harmless, Minot Soccer Association, and its affiliates, sponsors, league sponsors, employees, coaches, representatives and agents from and with respect to any claim, cause of action, liability, expense or obligation arising in connection with, or related to, such players participation in the league and related activities. I hereby grant permission to the team’s coaching staff, or league personnel, in my absence, to authorize and obtain medical care and treatment from any licensed physician, nurses or medical personnel to the extent deemed necessary by such physician, nurse or medical personnel and I assume full financial responsibility for said treatment. PLAYERS UNDER 18 require parent/guardian signature. Player Name (Print) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Player / Guardian Signature Date
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