KinderKicks Registration Form
Player's First Name *
Your answer
Player's Last Name *
Your answer
Gender *
Player's Date of Birth *
(mm/dd/yyyy)
MM
/
DD
/
YYYY
Player resides with *
Player attends school at *
Your answer
Mother's Contact Information
If not applicable type N/A
Mother's First Name *
Your answer
Mother's Last Name *
Your answer
Mother's Address *
Your answer
City *
Your answer
Zip *
Your answer
Mother's Email *
Your answer
Mothers's Phone *
Your answer
Father's Contact Information
If not applicable type N/A
Father's First Name *
Your answer
Father's Last Name *
Your answer
Father's Address *
Your answer
City *
Your answer
Zip *
Your answer
Father's Email *
Your answer
Father's Phone *
Your answer
AYSA Code of Conduct *
I, the parent/guardian of the above-named player, a minor, agree that we will abide by the Code of Conduct of Arizona Youth Soccer Association as described in https://usys-assets.ae-admin.com/assets/979/15/ASA%20Code%20of%20Conduct%205-30-18.pdf
AYSA Concussion Policy *
I, the parent/guardian of the above-named player, a minor, agree that we will follow the Concussion Policy of Arizona Youth Soccer Association as described in https://usys-assets.ae-admin.com/assets/979/15/ASA%20Head%20Injury%20Concussion%20Policy%20_%20Procedures%20(updated%205-30-18).pdf
Consent for Medical Treatment (Minor) *
As the parent or legal guardian of the above-named player, I hearby give consent for emergency medical care prescribed by a duly licensed doctor of medicine or dentistry.
Person to notify in an emergency *
Your answer
Phone Number of emergency contact *
Your answer
Agreement to Register *
I, the above-named parent or guardian of the above-named child, am agreeing to register the above-named child for the KinderKicks program.
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