Financial Assistance Form

Financial Assistance Form
Child Information / Informacion del Jugador
First Name / Nombre
Last Name / Apellido
DOB / Fecha de Nacimiento
(Day/Mo/Yr) (Dia/Mes/Año)
Gender / Sexo
M – Masc.
F – Fem.
M/F
Parent – Guardian Information / Informacion del Padre o Tutor
First Name / Nombre
Home Phone / Telefono de Casa
Last Name / Apellido
Relationship to Player
Relacion con el Jugador
Work Phone or Cell Phone / Telefono de Oficina o Celular
Street Address / Calle y Numero
City / Ciudad
State / Estado
Zip Code / Codigo Postal
Email
I understand that Los Angelitos de Encinitas may offer some financial assistance for my child to participate in
valuable programs in the Encinitas area. Such an offer is based upon strict rules that Los Angelitos de
Encinitas must follow in order to continue to operate. One such rule is that financial assistance may be
offered to my child because my child receives “free or reduced lunch” at my child’s public school. I promise
and guaranty to Los Angelitos de Encinitas that my child receives free or reduced lunch at a public school. I
know that Los Angelitos de Encinitas is relying on my promise and guaranty in making decisions about what
assistance may be offered.
Entiendo que Los Angelitos de Encinitas puede ofrecer algún tipo de asistencia financiera para que mi hijo
participe en programas valiosos en la zona de Encinitas. Esa oferta se basa en reglas estrictas que Los
Angelitos de Encinitas debe seguir para seguir funcionando. Una de esas reglas es que la ayuda financiera
puede ser ofrecido a mi hijo porque mi hijo recibe "almuerzo gratis o a precio reducido" en la escuela pública
de mi hijo. Prometo y garantizo a Los Angelitos de Encinitas que mi hijo recibe almuerzo gratis o reducido en
una escuela pública. Sé que Los Angelitos de Encinitas dependen de mi promesa y garantía en la toma de
decisiones sobre qué tipo de ayuda pueden ser ofrecidas.
Signature of
Parent / Guardian
Firma del padre o
tutor
Date
Fecha
California State Soccer Association - South
2012 -
2013
SEASONAL YEAR
FALL
YOUTH PLAYER REGISTRATION APPLICATION
Parent/ Guardian Information
*Required field
MI
First Name/Primero Nombre*
**At least one field is required
Last Name/Apellido*
Relation/Relacion*
Street Address/Dirección postal*
City/Ciudad*
State/Estado*
Home Phone/Teléfono de la casa*
Work Phone/Teléfono del trabajo*
Zip Code/Código postal*
Cell Phone/del teléfono celular *
Email Adress/dirección de correo electrónico*
Volunteer / Voluntario:
Coach
Gender/Sexo*
Sponsor
Patrocinar
Board
Tablero
Picture Day
Dia de la Foto
Coach
Entrador
Fields
Campos
Player Information
New Player
Jugador Nuevo
Returning Player
Jugaores que ya
If returning, Cal South Player ID Number:
M - Masculino
F - Feminino
First Name/Primero Nombre *
MI
DOB (MM/DD/YYYY)*
Rank
School/Escuela*
Grade
Last Name/Apellido *
Gender/Sexo*
ft.
Leauge/Liga*
Shirt Size
Seasons Played
Play Type
Juega el tipo:
Competitive
in.
lbs.
Height/Altura
Signature
Weight/Peso
Recreational
TOPSoccer
CCAP
Club*
Short Size
Sock Size
Age Group
Division
Team ID Number
Emergency Contact/contacto de emergencia #1 *
Phone/teléfono *
Emergency Contact /contacto de emergencia #2
Phone/teléfono
If applicable, list any medical problems(s)/physical limitation(s) the player has /Si procede, una lista de cualquier problema médico (s) / limitaciones físicas), el jugador ha:
As a parent or legal guardian of the above named player, I request that the registrant’s name be removed from the Association’s magazine, camp, ODP, and other program mailing
list.
Cal South Waiver
We, the registrant and the registrant's legal parent or guardian, hereby agree and acknowledge the following: (1) We agree to
abi de by t he r ul es of Cal S out h an d i t s af f i li at ed or g ani z at i ons a nd s p on s or s . ( 2) W e r ec ogni z e t h e i nher ent r i s k of s er i ous or
per m anent phy sic al i nj ur y and pos si ble deat h as s oci at ed wit h y out h s oc c er ac tivi ti es and gam es . I n consi der ati on f or Cal S out h
ac c ept i ng t h e y ou t h pl ay er ' s r egi s t r a t i on a nd par t i c i pat i on i n i t s s anc t i on ed y o ut h s oc c er l ea gues , t o ur nam e nt s and t e am t r av el
activities (“Youth Programs”), we hereby release, discharge and/or otherwise indemnify and hold harmless Cal South, its affiliated
or ga ni z at i ons an d s po ns or s , v ol unt ee r s , t hei r em pl oy ees a nd as s oc i at ed p er s onn el , i nc l udi ng t h e o wner s o f f i e l ds and f ac i l i ti es
utilized for the Youth Programs, against any claim, lawsuit or written demand, including but not limited to any claims for personal or
phy s i c al i nj ur y or deat h, by or o n b eh al f of t h e r egi s t r an t as a r es ul t of t he r egi s t r ant ' s par t i c i pat i on i n t he Y out h P r ogr am s an d/ or
T hank s gi v i ng. b ei ng t r ans por t e d t o o r f r om t he s am e, whi c h t r ans p or t at i o n we h er eby a ut h or i z e. ( 3) W e aut h o r i z e v er i fi c at i on of
t he r e gi s t r ant ' s dat e of bir t h f r om l egal r ec or ds t o be pr ovi ded t o a Cal S out h aut hori z ed r epr es ent ativ e f or t he l imit ed pur pos e of
verif yi ng t he Cal S out h pl ay er 's age and i denti ty .( 4) W e c ons ent t o em er genc y m edic al c ar e pr escri bed by a duly lic ens ed Heal t h
Car e P r ovi der or Dentist. This car e m ay be given under what ever c onditions are necess ary t o pr eserv e t he life, l imb or registrant 's
well-being and we h er eb y ag r e e t o b e f i n a nc i al l y r es p o ns i bl e f or al l c os t s as s oc i a t e d wi t h s uc h t r e a t m en t . ( 5) W e c o ns e n t t o C al
S o ut h t ak i ng ph ot o gr ap hs , v i de o r ec or di ngs , an d/ or s ou nd r ec or di ngs i n doc um e nt i ng t h e ac t i v i t i es of Cal S o ut h' s pr ogr am s an d
s er v i c es . W e her eby gr a nt C al S out h and t hei r af f i l i at es ' per m i s s i on t o u s e t he neg at i v es , pr i nt s , m ot i on pi c t ur es , v i deo/ audi o
t api ngs , or any ot h er r e pr od uc t i on of t he s am e f or C al S out h an d i t s af f i l i at es ' e duc at i o nal and pr om ot i on al pur p os es i n m a nu al s ,
on f l y er s , t h e internet, or other publications. We have read this release and waiver of liability and fully understand its terms. We
understand that we waive substantial rights by signing this form. We agree to waive all such rights above including the right to
file a legal action or assert a claim for personal or physical injury or death of any kind. We sign this release form freely of our
own free will.
Signature of Parent/Legal Guardian:
Refund Policy
As p a re n t/g u a rd ia n , I acknowledge
the refund policy: 75% if by May 31, 50%
if by July 31, 0% thereafter.
Fees: Micro $120/All others $200 (deduct $15
at March walk-in). After April 30 fees are
$130 Micro/$210.
I ni ti al her e:
For Club/League Use Only
Date Received
Birth Certificate Checked
Payment Received
Cash
Date
Check