Player's Full Name
Birthdate
Email
GenderMaleFemale
Street
Street 2
City
State
Zip Code
Grade
School
Parent/Guardian 1 Name
Phone
Parent/Guardian 2 Name
Parents/Guardian's Address (if different than above)
Parents/Guardian's Employer (name/address/phone)
Person 1 Name
Relationship
Person 2 Name
Family Doctor
Address
Insurance Carrier
Policy Number
Date of Tetanus Booster
Known allergies, including allergies to medicine
Any other medical problems
Person responsible for charges (if different than above)
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Language(s) spoken at home
Country of Birth
Is your child currently on a soccer team?YesNo
If yes, what position does he/she play?
If no, has he/she played on a soccer team before?YesNo
If yes, for what club/team did he/she play?
Child's shirt sizeYouth SmallYouth MediumYouth LargeSmallMediumLarge
Preferred Location---CBC-AliefArrowood-AliefBush–AliefLong Point—Spring BranchMilby--Southeast HoustonWestpark--AliefWilcrest-AliefFBA Warrior field—Spring BranchWestbury — Southwest HoustonHCC Stafford
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I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
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