Player InformationPlayer Name on Birth Certificate* First Last Primary Email Address* Primary Phone Number*Date of Birth*MM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender* Boy Girl Position(s) of Interest Forward Midfield Defender Goal Keeper Age Matrix 8 and under 1/1/17 – 12/31/17 9 and under 1/1/16 – 12/31/16 10 and under 1/1/15 – 12/31/15 11 and under 1/1/14 – 12/31/14 12 and under 1/1/13 – 12/31/13 13 and under 1/1/12 – 12/31/12 14 and under 1/1/11 – 12/31/11 15 and under 1/1/10 – 12/31/10 16 and under 1/1/09 – 12/31/09 17 and under 1/1/08 – 12/31/08 20 and under 1/1/07 – 12/31/05 Current Club* Residential Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian 1Name* First Last RelationshipMotherFatherGuardianPrimary Email Address* Verify Primary Email* Primary Phone* Same Address as Player's Address Mailing Address* City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent / Guardian 2Name First Last RelationshipMotherFatherGuardianPrimary Email Address Verify Primary Email Primary Phone Same Address as Player's Address Mailing Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Information for EmergenciesEmergency Contact Name Emergency Contact PhoneDoctor Name Doctor PhoneCaptchaWaiver This form must be acknowledged for each soccer player (participant) and, if the player is under 18-years old, must be acknowledged by the player’s parent or legal guardian. No player will be allowed to participate in soccer games without this form, properly executed, and on file. Soccer is a physical, contact, sport that involves the risk of injury. I assume all risks and hazards associated with my player’s participation in the sport. My player is in proper physical condition to participate in soccer practices, games, clinics, or soccer-related events; and has no illness, disease, existing injury, or physical defect that would be aggravated by participation. I will inform the coach or the event coordinator if this status changes. I further acknowledge that this risk may involve loss or damage to my player or my property, including the risk of death, or other unforeseen consequences, including those which may be due to the unavailability of immediate emergency medical care. I have a current medical consent form in force. My player will wear shin guards, properly-fitted and appropriate shoes, and other protective equipment (e.g., mouth-pieces), as provided by soccer rules, to all events. The club, league or tournament does not have personal injury insurance that covers my player’s participation. Therefore, I should have a current, active, personal injury insurance policy in force, which covers my player’s participation. Under any condition, I am responsible for any and all medical expenses arising from my player’s participation, both in practices and games and while travelling to and from these events. I have the right and responsibility to inspect the equipment and facilities prior to events and, if I believe that anything may be unsafe, I will advise the coach or supervisor of the condition and may refuse to allow my player to participate. Participation assumes consent. I authorize my player’s photograph, picture or likeness, and voice to appear in any documentary, promotion (including advertising), television, video, or radio coverage of the Club, league, tournament, or event – without compensation. I hereby release, waive liability, discharge, hold harmless, indemnify, and covenant not to sue, the United States Soccer Federation, the State Association, the Club, the league and tournament, their associated directors, administrators, officers, managers, employees, coaches, trainers, volunteers, sponsors and advertisers, and other agents, estates or executors, from any and all liability incurred in the conduct of, and my player’s participation in, their soccer programs. This includes owners, lessors, and lessees of premises, municipalities, government agencies, successors, heirs, and assigns. I have completely read this document and fully understand its contents. I acknowledge that I have given up substantial rights by accepting this document and that I do so voluntarily and attest to this on behalf of myself and my executors, personal representatives, administrators, heirs, next-of-kin, successors, and assigns. As the parent and natural guardian or legal guardian of the participating player, I hereby agree to the foregoing Waiver of Liability and Release for, and on behalf of, the participant (player/minor) named. I hereby bind myself, the minor, and all other assigns to the terms of the Waiver of Liability and Release. I represent and certify that I have the legal capacity and the authority to act for, and on behalf of, the minor in the execution of this Waiver of Liability and Release. Δ If you experience any problems with this form, please contact support@placerunited.com Get Updates Email Address* First Name* Last Name* Clinics & Camps Placer United Soccer Skills Camp Series Munchkin Madness
This form must be acknowledged for each soccer player (participant) and, if the player is under 18-years old, must be acknowledged by the player’s parent or legal guardian. No player will be allowed to participate in soccer games without this form, properly executed, and on file.
Soccer is a physical, contact, sport that involves the risk of injury. I assume all risks and hazards associated with my player’s participation in the sport. My player is in proper physical condition to participate in soccer practices, games, clinics, or soccer-related events; and has no illness, disease, existing injury, or physical defect that would be aggravated by participation. I will inform the coach or the event coordinator if this status changes. I further acknowledge that this risk may involve loss or damage to my player or my property, including the risk of death, or other unforeseen consequences, including those which may be due to the unavailability of immediate emergency medical care. I have a current medical consent form in force. My player will wear shin guards, properly-fitted and appropriate shoes, and other protective equipment (e.g., mouth-pieces), as provided by soccer rules, to all events.
The club, league or tournament does not have personal injury insurance that covers my player’s participation. Therefore, I should have a current, active, personal injury insurance policy in force, which covers my player’s participation. Under any condition, I am responsible for any and all medical expenses arising from my player’s participation, both in practices and games and while travelling to and from these events. I have the right and responsibility to inspect the equipment and facilities prior to events and, if I believe that anything may be unsafe, I will advise the coach or supervisor of the condition and may refuse to allow my player to participate. Participation assumes consent. I authorize my player’s photograph, picture or likeness, and voice to appear in any documentary, promotion (including advertising), television, video, or radio coverage of the Club, league, tournament, or event – without compensation.
I hereby release, waive liability, discharge, hold harmless, indemnify, and covenant not to sue, the United States Soccer Federation, the State Association, the Club, the league and tournament, their associated directors, administrators, officers, managers, employees, coaches, trainers, volunteers, sponsors and advertisers, and other agents, estates or executors, from any and all liability incurred in the conduct of, and my player’s participation in, their soccer programs. This includes owners, lessors, and lessees of premises, municipalities, government agencies, successors, heirs, and assigns. I have completely read this document and fully understand its contents. I acknowledge that I have given up substantial rights by accepting this document and that I do so voluntarily and attest to this on behalf of myself and my executors, personal representatives, administrators, heirs, next-of-kin, successors, and assigns.
As the parent and natural guardian or legal guardian of the participating player, I hereby agree to the foregoing Waiver of Liability and Release for, and on behalf of, the participant (player/minor) named. I hereby bind myself, the minor, and all other assigns to the terms of the Waiver of Liability and Release. I represent and certify that I have the legal capacity and the authority to act for, and on behalf of, the minor in the execution of this Waiver of Liability and Release.
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If you experience any problems with this form, please contact support@placerunited.com