Ramapo Valley Soccer Club ©1992

2012-13 Adult Open Play Nights Registration

Thank you for your interest in our programs. Please complete all required information (indicated by "!") and click the "Submit Form" button at the end of the form.

Player Information

* Firstname:

* Lastname:

* Gender:

Male

Female

* Birthdate (mm/dd/yyyy):

Contact Information

* Street:

* City:

* State:

* Zip:

* Home Phone (000-000-0000):

* Cell Phone (000-000-0000):

* Email Address (use lower-case):

2nd Email Address (use lower-case):

3rd Email Address (use lower-case):

Medical Information

* Insurance Provider:

* Primary Care Physician:

* Known Allergies or Medical Conditions:

None known

Yes, details follow

Specify Allergy / Condition:

Additional Information

Other Information:

Approval & Waiver Information

I/we, Parent/Guardian(s) of the above player, hereby give approval for his/her participation in any and all activities during the duration of the program registered for and indicated above. I grant permission to managing personnel or other league representative to authorize and obtain medical care from any licensed physician, hospital or medical clinic should the child become ill or injured while participating in league activities away from home or at other times when neither parent/guardian or emergency contact is available to grant authorization for emergency treatment. I understand the Ramapo Valley Soccer Club (RVSC) organizers, sponsors, supervisors are in no way responsible for an accident or injury that might occur before, during or after any practice and or games to any person; and do hereby waive, release, absolve, indemnify and agree to hold harmless the RVSC organization, league officials, supervisors, participants, sponsors, and persons transporting the child to and from activities, for any claim arising out of injury to the child, except to the extent and in the amount covered by accident and/or liability held by the local league. RVSC insurance is a secondary policy and has a deductible that must be covered by the parent or guardian.

I/we are age 21 or older & agree to the above terms. *

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2012-13 Adult Open Play Nights Registration