Valentis Athletica - Academy Registration
Player Information
First Name *
Middle Initial
Last Name *
Age Group Player is Registering for: *
Team - (Ages)
Gender *
Birth Date *
MM
/
DD
/
YYYY
Home Address *
City *
State *
OH
Zip Code *
Home Phone *
No dashes, spaces, or parentheses
Cell Phone
No dashes, spaces, or parentheses
Email Address
Parent Information
Mother's Name *
Mother's Cell Phone
No dashes, spaces, or parentheses
Mother's Email *
Fathers Name *
Father's Cell Phone
No dashes, spaces, or parentheses
Father's Email *
Where did you hear of us?
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 *
Required
Agreement for Electronic Submission: *
Required
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