Basalt Soccer Club Registration Form
IF POSSIBLE, PLEASE REGISTER ON-LINE AT
PO Box 1932, Basalt, CO 81621
See our website for registration, refund and team policies

Please fill out all fields as completely as possible. Incomplete registrations will not be processed. Registration Deadline is January 20th. Also payment plans and Early-bird discount endJanuary 20th.

  • Players are registered when they have completed and submitted: 1) Registration Form, 2) Payment (either full or partial if applying for scholarship), 3) Scholarship form, (if applicable) and 4) Player birth certificate and Player photo as required for U10 and up.
  • Payment can be made by credit card (online), mailed-in (to Club PO Box), or complete a scholarship application.
  • A Birth Certificate or Proof of age needs to be submitted for all players (once on file you do not need to submit again).
  • A small passport size photo is required yearly for all U10 - U18 players.
  • Fees (if registered by Jan 20th): U6 - $100 U8 -$125 U10 -$175 U12 - $225 U14 - $250 U18 - $225
  • Fees (if registered after Jan 20th): U6 - $100 U8 - $150 U10 - $200U12 - $250 U14 - $275 U18 - $250

Player Information (please print)

______/_____/_____

First Name Last Name M / F Date of Birth (mo/day/year)

______

School Grade (Fall 2016)Are you applying for a scholarship? If yes, did you complete form?

______

Have you played soccer before? If yes, for what club and coach? Special Requests

Parent/Guardian/Emergency Contacts (please print)

______

Father’s Name Home phoneCell phoneEmail

______

Mother’s Name Home phoneCell phoneEmail

______

Mailing Address City State Zip Code

______

Emergency Contact & Phone Number Physician & Phone Number

Payment

I have included $______in cash

I have included $______in the form of a check. Check #______

I authorize the Club to charge my Credit Card in the amount of $______

Name on Card:______
Billing Address:______

Card Number:______(Visa or Mastercard)

Expiration:______CVV Code:______

Parental Acknowledgement, Agreements and Waiver

1) I, ______, the parent or legal guardian of the registrant, a minor, agrees that I will abide by the rules and regulations of the Basalt Soccer Club (BSC), the Mountain Region League (MRL), The Colorado State Youth Soccer Association (CYS), the United States Youth Soccer Association (USYSA), and their affiliated organizations and sponsors.

2) I recognize the possibility of physical injury associated with soccer, and in consideration for BSC, MRL,CYS,USYSA accepting the registrant for their soccer programs and activities (the programs), I hereby release, discharge, and/or otherwise indemnify BSC, MRL, CYS, USYSA, its affiliate organizations, their employees and associated personnel (Whether paid or volunteer) as well as the owners of the fields and facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the program and/or being in the program and/or from the same, which transportation I hereby authorize.

3) I hereby represent and certify that the age of the registrant listed above is correct and that the registrant is physically fit to engage in the physically demanding, contact sport of soccer

4) CONSENT FOR MEDICAL TREATMENT (Minor). As the parent or legal guardian of the registrant, a minor, I hereby give consent for the emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent. I represent that I am the parent or legal guardian of the above registrant and that I have read and understand the above statements.

5) Photography: I hereby give consent for my child’s photo to be used by the Club or affiliates in promotional or social media content.

______

Parent/Legal Guardian SignaturePrint NameDate

BSCParentsshall conductthemselves in amannerthatexemplifiesgood behavior anda commitment toBSCcorevalues:Sportsmanship,Commitment, andLeadership.BSC parent expectationsinclude,but arenot limitedto thefollowing:

  • Parents agree to communicate and enforce the Player values above with their player.
  • Parentswillwatchthe gameform theoppositeside ofthefieldthatthe playersare on.
  • Parents will havetheir playerstogames andpracticeson timeandproperlyattired.Parentswillpick uptheir playerson timeafteragame orpractice.
  • Parentsshallrespectthecoaches,players,opponents, and officials.RespectandSupport thecoach’sdecision and referee’scallat alltimes.
  • Parentsshould bea parentand not acoach andresistthe urgeto critique.
  • Excuseaplayer if theyhaveto missa gameor practiceaheadof timetothecoach (eitherbynote,phonecall,email,orin person).
  • If you have a question or problem with a coach or referee you will report it through the proper board member.
  • Help clean up thefieldafter a gameand checkforuniformsor equipment playersmayhaveleft.
  • PLEASE consider taking some time to review the information available at
  • Parents may be asked to stop attending BSC events due to any inappropriate behavior.

______
Parent Name PrintedParent Signature

Players

BSCPlayersshall conductthemselves in amannerthatexemplifiesgood behavior anda commitment toBSCcorevalues:Sportsmanship,Commitment, andLeadership.BSC playerexpectationsinclude,but arenot limitedto thefollowing:

  • Playersareexpectedtoattendeverypracticeand game and give100%effortatall times.
  • Playersareexpectedtobeon timeand properlyattired (shorts,shin guardswithlong socks, andsoccershoes) foreverypracticeandgame.
  • Alwaystreat coaches,parents,officials, andopponents with respect.
  • Playersshall abstainfromtheuseof profaneor abusivelanguage.
  • Playersshalltreatwithrespectall BSCpropertyandequipment, theproperty ofotherathletes,and theproperty ofotherclubs andfields.
  • Allplayersmustmaintain acceptablegradesand learnerbehaviorsto beableto play in games.
  • Playerswill demonstratesportsmanship at alltimes:wins withoutboasting,loseswithoutexcuses, and a never quit attitude.
  • If a playerhasto missa gameor practice,theyneedtobeexcusedbytheir parents(eitherbynote,phonecall,email,orin personto thecoach)prior to theirabsence.

______
Player Name PrintedPlayer Signature

Basalt Soccer Club Medical Release Form
PO Box 1932, Basalt, CO 81621
Email: Website:

As the parent/legal guardian of ______, I request that in my absence the above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentist and staff duly licensed as Doctors of Medicine of 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. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medial facility to dispose of any specimen or tissue taken from the above-named player.

Player’s Date of Birth: _____/_____/______Date of Last Tetanus Booster: _____/_____/______
MonthDayYearMonthDayYear

Known Medical Problems:______

Known Allergies (including any allergies to medicine)______

Insurance Carrier:______Policy Number:______

Person Responsible for Charges: ______

Signature of Parent/Guardian:______

Mail to PO Box 1932, Basalt, CO, 81621 OR Fax to 970-927-3016 OR Email to