ROSTER/MEDICAL RELEASE FORM

Team Name / Age Group / Gender
Coach’s Name / Email / Home Phone / Cell Phone
POC Name / Email / Home Phone / Cell Phone

Statement of Informed Consent, Assumption of Risk, and Release

I have registered in the following activity or desire to participate in the following activity sponsored by the TriCounty Futsal (in conjunction with Calvert Soccer Association, Northern St. Mary’ St. Mary’s Youth Soccer and Waldorf Soccer Club): FUTSAL

I give my permission for any and all medical attention necessary to be administered to me or my child in the event of an accident, injury, sickness, etc. under the direction of the TriCounty Futsal and its representatives until such time as I can be contacted. I also understand that the TriCounty Futsal recommends physicals for children participating in the futsal program and requests that a parent or other designated responsible adult attend all events.
The team representative(s) identified above acknowledge that permission of all players legal guardians for partipation in TriCounty Futsal and agree to participate in the above program knowing that safety precautions will be taken, but realize the TriCounty Futsal and its representatives do not have accident insurance for the participants of this program. I do hereby release and hold harmless the TriCounty Futsal and its representatives their officials, employees, instructors and volunteers from any and all liabilities arising from any injuries that might occur during the supervised program. I also authorize TriCounty Futsal and its representatives to take photographs of me/my child for promotional and/or educational purposes. It is hereby stated and declared that the released information stated above is freely, willingly, and voluntarily made.

TriCounty Futsal consists of the following representatives:
Calvert Soccer Association, Northern St. Mary’s Soccer, St. Mary’s Youth Soccer, Calvert County Department of Recreation and Parks, St. Mary’s County Department of Recreation and Parks, Charles County Capital Clubhouse and/or Charles County Department of Community Services, St. Mary’s College of Maryland, King’s Christian Academy and Wilson Ennis Clubhouse.

OFFICIAL ROSTER

Minimum of 7 players must be listed. No more than 15 players may be listed. No more than 10 players may attend any single game and sit on player’s sideline.

All boxes MUST be completely filled in. Any missing information could disqualify team from participation.

Player 1 Full Name / DOB
Emergency Contact / Phone(s)
Player 2 Full Name / DOB
Emergency Contact / Phone(s)
Player 3 Full Name / DOB
Emergency Contact / Phone(s)
Player 4 Full Name / DOB
Emergency Contact / Phone(s)
Player 5 Full Name / DOB
Emergency Contact / Phone(s)
Player 6 Full Name / DOB
Emergency Contact / Phone(s)
Player 7 Full Name / DOB
Emergency Contact / Phone(s)
Player 8 Full Name / DOB
Emergency Contact / Phone(s)
Player 9 Full Name / DOB
Emergency Contact / Phone(s)
Player 10 Full Name / DOB
Emergency Contact / Phone(s)
Player 11Full Name / DOB
Emergency Contact / Phone(s)
Player 12 Full Name / DOB
Emergency Contact / Phone(s)
Player 13 Full Name / DOB
Emergency Contact / Phone(s)
Player 14 Full Name / DOB
Emergency Contact / Phone(s)
Player 15 Full Name / DOB
Emergency Contact / Phone(s)

I certify to the best of my knowledge that all information provided is accurate and understand my responsibilities/liabilities.

Printed Name: ______

Signature: ______

Date: ______