Olympic Development Program Registration Form
Winter 2013-2014

PLAYER INFORMATION:
First Name:
Middle Initial:
Last Name:
Birthdate: (format 02/01/1998)
Age Group:
Gender:
Boy Girl
Position (you may select more than one:
Forward Midfielder Defender GK
Are you a High School Player?
Yes No
Are you New to ODP?
Yes No
Street Address:
City:
State:
Zip:
Email Address:
Confirm Email Address:
G.P.A.:
Year of High School Graduation (ie: 2015):
Club Team:
T-Shirt Size:
Short Size:
Club Coach:
PARENTAL INFORMATION:
Father's First and Last Name:
Father's Email Address:
Confirm Father's Email Address:
Mother's First and Last Name:
Mother's Email Address:
Confirm Mother's Email Address:
Home Phone: (format 555-555-1212)
Father's Mobile Phone: (format 555-555-1212)
Father's Work Phone: (format 555-555-1212)
  Mother's Mobile Phone: (format 555-555-1212)
Mother's Work Phone: (format 555-555-1212)
MEDICAL INFORMATION:
Physician Name:
Physician's Phone Number: (format 555-555-1212)
Dentist Name:
Dentist's Phone Number: (format 555-555-1212)
Special Medical Requirements and Comments (do not use double/multiple dashes or -- in the comments):
Authorization for Medical Treatment:
I hereby give my consent to have an athletic trainer, coach, paramedic, and /or doctor of medicine or dentistry provide medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of such assistance and/or treatment.  This authorization does not cover major surgery unless the medical opinions of two licensed physicians or dentists concur in the necessity for the surgery are obtained before the surgery is performed.  Attempts will be made to contact parents of players participating in the program based on information provided on this form.
WAIVERS AND RELEASES:
Waiver of Liability:
Recognizing the possibility of physical injury associated with soccer an in the consideration for OYSAN/US Youth Soccer/USSF and its affiliated accepting the registrant for this program, I hereby release, discharge and/or otherwise indemnify OYSAN/US Youth Soccer/USSF, its affiliated organizations and sponsor's, their employees, volunteers, and associated personnel, including the owner of fields and facilities utilized by the program against claim by or on behalf of the registrant as a result of participate in the program.
Code of Conduct:
I will conduct myself in a manner respecting the facilities, other players, referees and the Coaching and Administrative staff of the US Youth Soccer Association while I am participating in the State, Regional and National US Youth Soccer ODP program. Further, I understand that if I am found to be using or in the possession of drugs or alcohol or in violation of the US Youth Soccer and/or the hosting organization's rules and regulations that this shall result in my immediate ejection from the program. I understand and accept the fact that if dismissed from the program or an event while traveling, I may be sent home immediately at my parent's expense by whatever means is most convenient for the program administrator. Further, if I am dismissed from the program or event, I understand program or event fees will not be reimbursed.
Agreement to Participate:
The OYSAN Board of Director along with the State Coaching Staff is responsible for the direction of the program. In accordance with the ODP program, as the athlete and a registered member of OYSAN, I agree to participate in and complete training and competitive matches as outlined by the coaching staff. This program is duly authorized through the USSF as the Olympic Development Program for Soccer.
Agreement for Electronic Submission:
I/we (above indicated) hereby acknowledge the I/we have reviewed this and form and caused it to be electronically executed with the intent to be bound to the terms contained herein.
PAYMENT INFORMATION:

$150 Winter Training, $200 Camp Deposit, $50 Spring Training. 2000/2001 Birth Year is INVITE ONLY. 2002 Birth Year DOES NOT PAY A CAMP DEPOSIT

Select Registration Type Below:


Type of Credit Card:
Name on Credit Card: (format Jim Smith)
Credit Card Number: (format: 12345678911234)
Cardholder Street Address:
Cardholder Zip:
Credit Card Expiration Date:
Month: Year: