Valentis Athletica - Academy Registration
Player Information
First Name *
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Middle Initial
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Last Name *
Your answer
Age Group Player is Registering for: *
Team - (Ages)
Gender *
Birth Date *
MM
/
DD
/
YYYY
Home Address *
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City *
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State *
OH
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Zip Code *
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Home Phone *
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Your answer
Cell Phone
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Your answer
Email Address
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Parent Information
Mother's Name *
Your answer
Mother's Cell Phone
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Your answer
Mother's Email *
Your answer
Fathers Name *
Your answer
Father's Cell Phone
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Your answer
Father's Email *
Your answer
Where did you hear of us?
Your answer
Waiver of Liability: I, the parent/guardian for the above child, release, waive, acquit and forever discharge, the Valentis Athletica Soccer Club, board, employees, coaches, representatives and agents from any and all claims, liabilities, expenses, injuries, damages, and losses, arising out of or from the above child's participation in the Valentis Athletica tryout which I am registering my child to attend. I further agree to indemnify the Valentis Athletica Soccer Club, board, employees, coaches, representatives and agents from any and all claims, liabilities, attorney's fees, expenses, injuries, damages, and losses, arising out of or from the above child's participation in the Valentis Athletica tryout. *
Required
Consent for Medical Treatment(Minor): I hearby give my consent to have a coach, athletic trainer, emergency personnel and/or a doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment. Additionally, I have reviewed the following information with my child/children regarding concussions: http://www.oysan.org/Assets/Concussion+2013/Concussion+Info+Sheet.pdf *
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Agreement for Electronic Submission: *
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