Official PSP Sports Registration FormSoccer 2011

Player Name_______________________________________ Age______ Group________ Player Name_______________________________________ Age______ Group________ Player Name_______________________________________ Age______ Group________ Player Name_______________________________________ Age______ Group________ Player Name_______________________________________ Age______ Group________ Parents/Guardians Name_____________________________________ Parents/Guardians Name_____________________________________ Parents/Guardians Name_____________________________________ Parents/Guardians Name_____________________________________ How many Parents/Guardians will be playing? Circle one 0 1 2 3 4 Do Parents/Guardians want to help and/or coach? Yes (check a box below) No Helper Assistant Coach Head Coach Home Phone Number ( ) Cell Phone Number ( ) -

Email______________________________________ Street address___________________________________ City_____________________________ State CA Zip_______________

What school and/or support group are you enrolled? _______________________________________________________________________

Is ANYONE living in your home, regardless of their participation in PSP Sports programs, enrolled in a public school program (this includes day campus, ISP, or Office Use Only charter school)? Yes No Payment Rec'd by _______ Amount_________ Check #________ Cash Donation Amount_________ Check #________ Cash

AGREEMENT AND RELEASE OF LIABILITY

I, the undersigned, understand the following: I, the registrant, or the parent/guardian of the registrant, a minor, agrees that we will abide by the rules of PSP Sports. I am aware that recreational activities can be hazardous and I am voluntarily participating in these activities with knowledge of the hazard involved and hereby agree to accept any and all risks of injury or death. PSP Sports is not responsible for participants injuries or damages occurring from hazardous recreation activities. PSP Sports does not provide participants with medical insurance or treatment for injuries. I agree to hold harmless and release PSP Sports, its officers, agents and employees from any and all liability arising from or related to my participation in PSP Sports program activities. This release includes, but is not limited to, all liability for death, personal injury, or property damage resulting from the active or passive negligence of PSP Sports or its agents or any defective or hazardous condition of any property or equipment owned, or facilities utilized by PSP Sports. I am responsible for any loss, theft, or damage to personal or PSP Sports equipment, articles or facilities while using said equipment, articles, and/or facilities. Participant Signature (18 & older) ____________________________________ Date ____________________________ Or Parent/guardian Signature __________________________________________ Date ____________________________

AGREEMENT WITH RULES

By signing this I agree and affirm that I have read and that my family will abide by the Statement of Faith, Home Education Philosophy, Code of Conduct, and Dress Code at every PSP Sports event. I also affirm that any guest of my family will adhere to the Code of Conduct and Dress Code at all PSP Sports events. I have no one living in my home, regardless of their participation in PSP Sports programs, which are enrolled in a public school program (including day campus, ISP, or charter school). At least one parent/guardian must stay with their sports player during all PSP Sports events. I also understand that all fees are non-refundable and non-transferable. PSP Sports reserves the right to refuse service to anyone for any reason, at any time, without explanation or refund.

Participant Signature (18 & older) ____________________________________ Date ____________________________ Or Parent/guardian Signature __________________________________________ Date ____________________________

PHOTO DISCLOSURE By enrolling your family in any PSP Sport program you agree and understand that photos may be taken and used for publicity purposes including, but not limited to: brochures, flyers, news releases and other print, social or broadcast media.
Participant Signature (18 & older) ____________________________________ Date ____________________________ Or Parent/guardian Signature __________________________________________ Date ____________________________