Player Information

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* 2. Player Name (First & Last Name)

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* 3. Player Date of Birth (MM/DD/YYY)

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* 4. Grade

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* 5. Has your child participated in Soccer for Success before?

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* 6. Does your child receive free/reduced price lunch at school during the school year?

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* 7. Gender

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* 8. Ethnicity

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* 9. School Name

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* 10. Jersey Size

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* 11. Parent/Guardian Information

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* 12. Are you/family member in the military?

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* 13. Relationship to Child

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* 14. Are you interested in being a volunteer?

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* 15. Emergency Contact (Other than Parent/Guardian) 

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* 16. Secondary Emergency Contact (Optional)

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* 17. I/we, legal parent/guardian(s) of above-named participant, agree to the following: 1) Give permission to the Houston Parks and Recreation Department and the U.S. Soccer Foundation to collect and record data, including Body Mass Index (BMI) weight and height, about my child with the understanding that all information obtained will remain private, and that any responses publicly reported will be grouped together with other participants of this program and that my child will not be individually linked to his/her response. Only the staff approved by the U.S. Soccer Foundation will be able to view his/her responses. 2) Authorize release of data and information collected by my child’s current or former school(s) to verify information and utilize information for group reporting with an understanding that only staff approved by the U.S. Soccer Foundation and Houston Parks and Recreation Department will have access to the information. I hereby certify that the statements in this application are correct and true.

As the child(ren)’s parent/guardian, I hereby grant a license to the U.S. Soccer Foundation, and their agents, including any advertising agencies, to use and to license others to use the child(ren)’s name, recorded voice, image, picture or likeness in any live or recorded audio, video or photographic display or other transmission for purposes of promotion and publicity in connection with the Soccer for Success program and any future U.S. Soccer Foundation events or programs and hereby waive any rights of compensation or ownership thereto.

I HAVE READ, AND I UNDERSTAND, AND I VOLUNTARILY SIGN THIS MODEL RELEASE AND AUTHORIZATION TO VIDEO/PHOTOGRAPH.

I, the undersigned, understand that participation in the U.S. Soccer Foundation’s Soccer for Success program (“Soccer for Success”) involves certain inherent risks of injury, despite all safety precautions taken by the U.S. Soccer Foundation and operators. 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 Soccer for Success program. 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 U.S. Soccer Foundation staff and operators to take whatever action is necessary to care for my child(ren). I hereby give permission for the U.S. Soccer Foundation staff and operators 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 U.S. Soccer Foundation 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 U.S. Soccer Foundation, 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.



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* 18. Parent/Legal Guardian Signature

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