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DO NOT WRITE IN THIS BOX U10 U12 U14 U17 BOY GIRL

Mail to:

Number: _______ Deposit: Y N

Color: ___________ Check # _________

Mill River United Soccer PO Box 205 N. Clarendon, VT 05759


RUTLAND RECREATION AND PARKS DEPARTMENT

PROGRAM INDOOR SPORTS at GIORGETTI ARENA


FIRST NAME:___________________ LAST:________________________Grade_____ D.O.B.__________ M/F Parents name:_____________________________ ___________________________________________________ ADDRESS:_____________________________ HOME PHONE: ________________CELL: ________________ CITY/STATE/ZIP ____________________________________________________________________________ EMAIL ADDRESS: __________________________________________________________________________
ARE YOU A RUTLAND CITY RESIDENT? YES / NO PLEASE CIRCLE THE PROGRAM THAT APPLIES U10 Boys U10 Girls U12 Boys U12 Girls U14 Boys U14 Girls U17 Girls

Shirt size:

YS

YM

YL AS

AM

AL AXL

INFORMED CONSENT
I, the undersigned participant acknowledge, agree and understand that: Participation in this sport/activity is hazardous and may result in injury and that participation is potentially dangerous to myself, my child and others. I also certify that myself and/or my child is physically capable of participating in this activity/program. Further, I agree that in consideration for permission to participate in the City of Rutlands sponsored programs or take part in activities at their facilities, I assume all risks of injury to myself and/or my child incurred or suffered while on city premises while participating in programs. As a matter of caution, the Rutland Recreation and Parks Department strongly recommends that all participants have accident and health insurance while taking part in programs or activities held on city premises. RELEASE: In consideration of your accepting this application in the Rutland Recreation Departments program or using their facilities, I hereby for myself, my heirs, executors and administrators, waive and release any and all rights and claims for damages I may have against the City of Rutland, the Rutland Recreation and Parks Department, their agents, representatives and assigns for any and all injuries suffered by me in this program or activity.

_____________________________________________________________________ Signature of Participant or parent/guardian if under age 18 Date

Mill River United Soccer


Recognizing the possibility of physical injury associated with soccer and in consideration for Mill River United Soccer/VSA/USYS/USSF and its affiliates accepting the registrant for its soccer programs and activities (the Programs) I hereby release, discharge and/or otherwise indemnify Mill River United/VSA/USYS/USSF, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrants participation in the Programs, and/or being transported to or from the same, which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in the Programs. Therefore, I grant the designated team personnel my permission to act as my surrogate for my child in the area of obtaining medical treatment by a doctor of medicine or dentistry. I also assume the financial responsibility for any medical treatment for my child. Signature of Parent/Guardian:_______________________________________________Date:_______________

Registration Fee: $65