Printed Name of Guardian/Parent:

:Signature

*** Email address will be used for club information and news ***

Registration Form**Player Information must match Birth Certificate**

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Health Insurance Company:

Email ***

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Parent/Guardian Names

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Waiver: I do hereby expressly and specifically assume all of the risks which attend the game of soccer and any other relatedactivities, including but not limited to physical contact and physical injuries. I agree to indemnify and hold harmless TheMSC United Soccer Club and The East Valley Sports Academy, it officials, coaches and members including but not limited toany adjoining facilities from any and all claims, suits, or proceedings arising allegedly or in reality out of the acts oromission and participation of the undersigned in any related activity. I also agree to all rules and regulations of The MSCUnited Soccer Club.

Consent for Medical Treatment (minor): As the parent or legal guardian of the above player, I hereby give consent foremergency medical care prescribed by a duly licensed doctor of medicine or dentistry. This care may be given underwhatever conditions are necessary to preserve the life, limb, or well-being of this minor, named above.

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MSC United

Group Number: Physician and Phone:

MSC United Committments: All Club members and parents are required to volunteer their time with all MSC United tournaments. Our tournaments underwrite many functions of the club to benefit all of the players and parents. As a member of this club, everyone is required to donate their time in support. The volunteer time required is 4 hours per player. A fee of $50 can be paid in lieu of each 4 hour requirement.

Medical Release Notarization(Recommended In-State play, Required out-of-state)

Subscribed and Sworn to me this day of

Day Month Year

Signature_______________________________

Date:

The undersigned acknowledges they have read, understood and agree to the terms listed in the MSC United Parent/Player agreement. Any violation of this policy will be dealt with in an appropriate manner.

Our club’s goal is to maintain a reputation of excellence and these rules have been established to make our environment more professional, enjoyable and safe for everyone.

Please discuss any concerns or ideas with the officers of the club or the board members. In doing so you are exercising your rights as a member of the MSC United Soccer Club.

Most minor violations of the Player and Parent Agreement should be resolved within the team, through the team manager and team coach. Serious or unresolved violations should be reported initially to the Director of Coaching who will then involve the Club President, if deemed necessary. The Club President will conduct a review of the situation and present the findings to the Board of Directors which will make the final determination of what action, if any, may be appropriate. If action is necessary, the available options range from a caution or warning, to requiring a personal apology, probation, suspension from playing or attending games as the case might be, or as a final step, expulsion from the Club.

A Parent or a Player, in certain situations, including the removal of a player from the Club, will be both allowed and required to attend a hearing before the Board of Directors of the Club. As a member of the Club, you are responsible for your own actions, and will be held accountable for same.

I/We acknowledge that we have read these rules and agree to abide by the policies and rules in this agreement. Player Name: __________________________________________________________

Player Signature: _______________________________________________________

Parent/Guardian Name: _________________________________________________

Parent/Guardian Signature: ______________________________________________ Date: _____________________________

Team: ________________________

MSC United Soccer Club 4406 E. Main Street, #102 PMB86

Mesa, AZ 85205 www.mscunited.org

MSC United Parent/Player Agreement Signature page

Code of Conduct

The Arizona Youth Soccer Association strives to provide the best possible environment for youth

players and play an important role in promoting the physical, social, and emotional development of

young people. Therefore, it is essential for parents, coaches, spectators, and officials to encourage

youth athletes to embrace the values of good sportsmanship. Furthermore, parents, coaches,

spectators, and officials involved in youth sports events should be models of good sportsmanship and

should lead by example by demonstrating fairness, respect, and self-control. The Arizona Youth

Soccer Association is committed to establishing an environment that is safe and fosters optimal

learning opportunities for all our players.

To maintain the reputation of the league and the learning environment AYSA has formulated this

Code of Conduct and requires that you commit to be responsible for your words and actions while

attending, coaching, officiating, or participating in AYSA and that you conform your behavior to the

following Code of Conduct:

1. I will treat coaches, players, opponents, referees, spectators and all other individuals with

respect.

2. I will not engage in any behavior which would endanger the health, safety, or wellbeing of

any coach, parent, player, participant, referee, or any other attendee.

3. I will not use drugs, alcohol or tobacco products while involved in any youth soccer

activities, whether training, attending, or officiating games.

4. I will not use profanity, obscenity or any other offensive language.

5. I will endeavor to ensure that no parents, spectators or anyone associated with my

team to use profanity, obscenity or any other offensive language while within the

hearing of players or officials.

6. I will not engage in verbal or physical abuse towards any other coach, player, parent,

spectator, participant, or official.

7. I will be punctual; arriving at games and practice well before the start time to have cleats,

shin guards, and other training gear to be checked.

All players should communicate any and all injuries, illness, conflicts or problems to the head coach

in a timely manner, including their intent to participate in school sports or activities.

As a spectator and/or parent I will also:

1. I will calmly watch play and not shout instructions to my child or other players.

2. I will not question the calls of the referee or the actions of coaches.

3. I will provide encouragement to any and all players.

4. I will support my child’s efforts to be on time and prepared for all training sessions,

games and other team related activities.

5. I will make sure my child comes to training sessions and games with appropriate

equipment.

6. Except in the case of an emergency, I will refrain from entering the team bench area and

discussing issues with the team or coach, unless asked to do so by the coach.

Anyone who fails to conform to the preceding Code of Conduct or if a spectator receives a red card

by an official while attending, coaching, training, officiating or participating in any event sanctioned

by AYSA will be subject to the penalties listed:

1. First Offense: Must watch an interactive training video regarding anger management and

good behaviors at games.

2. Second Offense: $250 fine.

3. Third Offense: $500 fine and expulsion for one year.

All charges will be made directly to the Parent/Fan/Coach, NOT the club.

By signing I understand the code of conduct as well as the penalties and understand that if I violate

the code of conduct I will be subject to the penalties listed.

Player Signature Date

Parent Signature Date

Parent Signature Date

Staff Signature Date

Team Name Club League

As the parent/legal guardian of __________________________ I request that in my absence the above-named player

to be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians,

dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or

nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the

above minor. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-

being of my dependant. I have not been given a guarantee as to the results of examination or treatment. I authorize

the hospital or medical facility to dispose of any specimen or tissue taken from the above-named player.

Date of player’s birth: _____/_____/_____ Date of last tetanus booster: _____/_____/_____ MONTH DAY YEAR MONTH DAY YEAR

Known allergies of this player, including any allergies to medication _______________________________________

______________________________________________________________________________________________

Are there any other medical problems that should be noted: _____________________________________________

Family Physician: _________________________________ Telephone: __________________________________

Name of parent/legal guardian: _____________________________________________________________________

Address: ______________________________ City: _____________________ State: _____________ Zip: ________

Telephone: ( ) ______________________ ( ) ______________________ ( ) ____________________ HOME WORK CELL

Person responsible for charges (if different from above): _________________________________________________

Address: ______________________________ City: ______________________ State: ___________ Zip: ________

Telephone: ( ) ________________________ ( ) ______________________ ( ) __________________ HOME WORK CELL

Person to notify if parent/guardian is unavailable: ______________________________________________________

Telephone: ( ) ________________________ ( ) ______________________ ( ) __________________ HOME WORK CELL

Insurance Carrier: _______________________________ Policy number: __________________________________

I HEREBY AUTHORIZE THE OFFICE, LEADER, OR COACH, AGENT(S) OF THE ARIZONA STATE YOUTH

SOCCER ASSOCIATION TO TRANSPORT AS REQUIRED THE ABOVE MINOR TO AND FROM THE

ASSOCIATION SPONSORED ACTIVITIES INCLUDING, BUT NOT LIMITED TO ATHLETIC AND SOCIAL

EVENTS.

Parent/legal guardian signature: ________________________________________ Date: ___________________

STATE OF ________________}

} ss. (Seal)

COUNTY OF ______________}

On this ____ day of _________, 20___, before me personally appeared ______________________ (name of signer)

whose identity was proved to me on the basis of satisfactory evidence to be the person whose name is subscribed to

this document, and who acknowledged that he/she signed the above document.

Notary Public _______________________________________

My Commission expires: _______________________________

****This document expires one year from the date of Notary, or the next playing season*****

HEAD INJURY/CONCUSSION MANAGEMENT PROTOCOL

What can happen if my child/player keeps on playing with a head injury/concussion returns too soon?

Athletes with the signs and symptoms of concussion should be removed from play immediately. Continuing to play with the signs and symptoms of a concussion leaves the young athlete especially vulnerable to greater injury. There is an increased risk of significant damage from a concussion for a period of time after that concussion occurs, particularly if the athlete suffers another concussion before completely recovering from the first one. This can lead to prolonged recovery, or even to severe brain swelling (second impact syndrome) with devastating and even fatal consequences. It is well known that adolescent or teenage athlete will often under report symptoms of injuries. And concussions are no different. As a result, education of administrators, coaches, parents and students is the key for student-athlete’s safety.

If you think your child/player has suffered a head injury/concussion

Any athlete even suspected of suffering a concussion should be removed from the game or practice immediately. No athlete may return to activity after an apparent head injury or concussion, regardless of how mild it seems or how quickly symptoms clear, without medical clearance. Close observation of the athlete should continue for several hours. “a youth athlete who is suspected of sustaining a concussion or head injury in a practice or game shall be removed from competition at that time” and

“…may not return to play until the athlete is evaluated by a licensed heath care provider trained in the evaluation and management of concussion and received written clearance to return to play from that health care provider”. The AYSA “Concussion Return to Play Form” http://www.azyouthsoccer.org/UserFiles/file/AYSA%20-%20Concussion%20Return%20to%20Play%20(3)%20(1)2015-16.pdf) must be completed and signed by the licensed health care provider trained in the evaluation and management of brain injuries. This form must be submitted to the AYSA office.

Licensed Health Care Providers acceptable to make the determination: 1. Medical Doctors (MD) 2. Doctor of Osteopathy (DO) You should also inform your child’s coach if you think that your child/player may have a concussion. Remember, it’s better to miss one game than miss the whole season. And when in doubt, the athlete sits out. For current and up-to-date information on concussions you can go to: http://www.cdc.gov/ConcussionInYouthSports

_________________________ _______________________________ ________ Student-Athlete Name Printed Student-Athlete Signature Date ___________________________ _______________________________ ________ Parent or Legal Guardian Printed Parent or Legal Guardian Signature Date ___________________________ _________________________________ _________ Coach Name Printed Coach Signature Date (06/17/2015)