Midwest Soccer Academy
Team Roster
Today's date__________________________

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of Midwest Soccer Academy it's affiliated organizations and sponsors. I understand it is my responsibility to promote good sportsmanship by setting a positive example for the youth participating in Midwest and failure to do so will result in disciplinary actions. Recognizing the possibility of physical injury associated with indoor soccer/futsal and in consideration for the Midwest Soccer Academy accepting the registrant for it's programs and activities, I hereby release, discharge and/or otherwise indemnify Midwest Soccer Academy, it's affiliated organizations and sponsors, their employees and associated personnel, including the owners of gymnasiums and facilities utilized for Midwest Soccer Academy, against any claim by or on behalf of the registrant as a result of the registrant's participation in Midwest Soccer Academy. As the parent or legal guardian of the named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent. And, I hereby acknowledge that all information provided on this roster is complete and accurate to the best of my ability. EACH ADULT, PARENT, GUARDIAN, COACH, ASST. COACH, MANAGER, VOLUNTEER MUST INITIAL TO SHOW AGREEMENT WITH ALL THE ABOVE STATEMENTS.


Team Name____________________________________________Age______________Grade______________

COACH'S NAME________________________________HOME PHONE_________________CELL PHONE_________________

EMAIL ADDRESS______________________________

ASST. COACH'S NAME______________________________HOME PHONE_________________CELL___________________

EMAIL ADDRESS______________________________

NAMEJERSEY #DOBAGEPARENT INTIAL

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