H-Town Soccer Academy Spring 2021 Tryout Registration Form Player Information/Información del participante Question Title * 1. New Player/Jugador que Nuevo No (Please Put Your Jersey Number Below)/No(Favor de poner su numero de camisa abajo) Yes Jersey Number (Only RETURNING players/Solamente jugadores REGRESANDO) OK Question Title * 2. Player First Name/Nombre de Jugador OK Question Title * 3. Player Last Name/Apellido de Jugador OK Question Title * 4. Date of Birth/Fecha de Nacimiento (MM/DD/YYYY) OK Question Title * 5. Gender/Sexo Male Female OK Question Title * 6. Ethnicity/Ethnica African-American/Afroamericano American-Indian/Native Alaskan/Indígena-Americano/Indígena de Alaska Asian/Asiático Caucasian/Caucásico Haitian/Haitiano Hispanic/Latin/Hispano/Latino Pacific Islander/Isleño Pacifico Other/Otro (please specify/por favor especifica) OK Question Title * 7. Jersey Size YS YM YL AS AM AL AXL OK Question Title * 8. Shorts Size YS YM YL AS AM AL AXL OK Question Title * 9. Socks Size S M L OK Question Title * 10. In the past 24 hrs as your player experienced any of the following symptoms? (Check all that apply)/En las ultimas 24 horas su jugador(a) a sentido alguno(as) de las siguientes sintomas? (seleccione todo lo que aplique) Fever/Fiebre Fatigue/Fatigo Coughing/Tos Headache/Dolor de Cabeza Sore throat/Dolor de Garganta Been in contact with anyone who has shown these symptoms/Estado en contacto con alguien que muestra estas sintomas Been in contact with anyone who has tested positive for COVID-19/Estado en contacto con alguien que probo positivo con COVID-19 None of the above/Ninguno de las respuestas arriba OK Question Title * 11. Parent/Guardian InformationInformación de Padre(s) Name/Nombre Address/Dirección City/Ciudad State/Estado -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code/Código Postal Email Address/Correo Electrónico Phone Number/Teléfono OK Question Title * 12. Relationship to ChildRelación al niño(a) Parent/Padre Legal Guardian/Tutor Legal Foster Parent/Padre Adoptivo Grandparent/Abuelitos Sibling/Hermano o Hermana Other Relative/Otro Pariente OK Question Title * 13. Emergency Contact (Other than Parent/Guardian) Contacto en caso de Emergencia (Otro que no sea Padre/Tutor Legal) Name/Nombre Relationship to Child/Relación al niño(a) Phone/Teléfono OK Question Title * 14. I, the undersigned, understand that participation in the Houston Parks and Recreation Department's (HPARD) H-Town Soccer Academy involves certain inherent risks of injury, despite all safety precautions taken by the HPARD. Therefore, as parent and/or guardian, I will assume all risks, injury or illness, for my child(ren) that may occur during the participation in any activities or use of facilities associated with the H-Town SA. In the event that my child(ren) need medical treatment due to accident or injury or natural causes while registered and participating in the Soccer for Success program, I authorize the HPARD staff and operators to take whatever action is necessary to care for my child(ren). I hereby give permission for the HPARD staff to use their best judgment in arranging for my child(ren)’s emergency medical treatment in addition to contacting me to the best of their ability. I certify that my child(ren) is/are fully covered by medical insurance and that I am fully responsible for all costs incurred due to medical or dental treatment as deemed necessary by the HPARD staff and operators.By signing this form, I acknowledge that I am aware of the potential risks of participation in any activities or use of facilities associated with the Soccer for Success program, and in no way hold the HPARD, its respective parent, its subsidiaries or affiliates, or their respective management, agents, employees, directors, officers, sponsoring agencies, volunteers or the facility or its operators, coaches, officials, or advertisers, (individually and collectively, the "released parties"), liable for any injury that my child(ren) may sustain. I, FOR MYSELF, MY SPOUSE AND MY CHILD(REN), DO FURTHER RELEASE, ABSOLVE, INDEMNIFY, AND HOLD THE RELEASED PARTIES HARMLESS AGAINST ANY CLAIMS OF INJURY OR DEATH TO MY CHILD(REN) IN CONNECTION WITH ANY AND ALL OF THE ACTIVITIES MENTIONED. I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MEDICAL RELEASE/WAIVER/INDEMNITY AGREEMENT. Agree OK Question Title * 15. Parent/Legal Guardian SignatureFirma de Padre OK DONE