LVSA Competitive Try-Outs Registration 2011-2012

Player's information
Player's First Name *	Last Name *	Street Address	Apartment#
Birthday MM* / DD* / YYYY* M/F		City	Zip Code
Favorite Position	Previous Club Team	Email Address	Home Phone
Referred by
Any known health problems?
Parent or Guardian Information
Mother's First Name *	Last Name *	Father's First name	Last Name
Mother's Email *	Mother's Phone *	Father's Email	Father's Phone

I do hereby expressly assume all of the risks which attend the game of soccer and any other sports or related activities, including but not limited to physical contact and physical injuries. I agree to indemnify and hold members including but not limited to any adjoining facilities and Las Vegas Sports Academy from any and all claims, suits, or proceedings arising allegedly or in reality out of the acts of omission and participation of the undersigned in any or related activity. I also agree to all rules and regulations of Las Vegas Sports Academy . Parent or Guardian Consent * As the parent or legal guardian of the above player, I hereby give consent for emergency medical care prescribed by a duly licensed doctor of medicine or dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of this minor, named above. Consent for Medical Treatment * I understand that as part of our child’s participation in Las Vegas Sports Academy, photos, videos, and quotations may be taken for use in publications and reports about the program. We further understand that members of the news media invited to cover the program may take photos, videos and quotations. We grant permission to use such materials for the promotion of the program. Media Release * By checking this box, you agree to use an electronic signature in lieu of a paper-based signature. You understand that electronic signatures, just like your signing a piece of paper, are legally binding in the United States and in other countries. You further agree not to electronically sign any form without first reading it and ensuring you have accurately filled out the form to the best of your knowledge. Parent or Guardian Consent *
MM/DD/YYYY
* Required Information