rage Flight EVALUATION REGistration

NEW THIS YEAR: We are asking ALL parents to register their kids for the placement process by completing the registration form at the bottom of this page. This pre-registration process will allow us to properly prepare with staff and equipment. ALL INFORMATION IS STRICTLY CONFIDENTIAL.

EVALUATION PRE-REGISTRATION FORM

All fields in red are required

Player Information

Age Group:

U12 U14
Please make a selection.

First Name:

A value is required.

Last Name:

A value is required.

Address:

A value is required.

City:

A value is required.

State: A value is required. Zip: A value is required.Invalid format.

Phone:

A value is required.Invalid format.(Format: 916-555-1212)

Birth Date

A value is required.Invalid format.(Format: 12/25/1992)

Field Position:

Field Player Goal Keeper

Club/Team Played on Last Season:

Parent Information

First Name:	A value is required.	Last Name:	A value is required.
Email:	A value is required.Invalid format. Retype Email: A value is required.The values don't match.
Phone:	A value is required.Invalid format. (Format: 916-555-1212)	Cell Phone:
Address:
Mark here if address is the same as player's information
Street:
City:	State: Zip:

Emergency Information

Emergency Contact:	A value is required.
Emergency Phone:	A value is required.Invalid format.(Format: 916-555-1212)
Doctor to Notify:	A value is required.
Doctor Phone:	A value is required.Invalid format.(Format: 916-555-1212)

Parent/Guardian Waiver

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I, the undersigned parent or legal guardian of the above player, a minor, acknowledge that participation in soccer involves risk of severe, permanent physical injury, and death. For myself, and on behalf of the above player, we willingly and voluntarily accept and assume all such risk. In consideration of permitting the voluntary participation of the above-named participant in this tryout program, for myself and on behalf of the above player, I hereby release, discharge and agree to hold harmless Pleasanton RAGE, its employees, volunteers, officials, sponsors, and other representatives from any and all claims, demands, costs, expenses, and compensation arising out of or in any way related to any injury or other damage that may result to said participant while participating in any Pleasanton RAGE sponsored event, including any physical or other injury caused by the negligence of any such person while performing his/her duties at any time.
I HAVE READ THE DISCLAIMER, ASSUMPTION OF RISK, AND WAIVER AND FULLY UNDERSTAND THE TERMS OF EACH. I UNDERSTAND THAT I AND THE ABOVE PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY AGREEING TO THESE TERMS, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT FOR MYSELF AND ON BEHALF OF THE ABOVE

Agree
You must agree to these terms to submit this form.

NOTE: If the form doesn't go to the "Thank You" page after you SUBMIT, please scroll up and review your input -- any errors on the form will show up in red - please correct any errors, and then re-submit!

Last Updated: May 15, 2012