PLAYER INFORMATION

Player Name*

Address

Street Address City State ZIP Code

Birth Date*

MM

DD

YYYY

Phone*

Position*

Secondary Position*

Prior Club*

2*

Gender*

Male
Female

Medical Condition

Y
N

Medical Condition Description

Comments

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name*

Home Phone*

Mobile Phone

Parent/Guardian Email*

Parent/Guardian Name #2

Home Phone

Mobile Phone

Parent/Guardian #2 Email

As the parent/legal guardian of the above-named player, or player age 18 or over by clicking submit I hereby give consent for 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 agree to hold harmless UC Premier and it agents and employees and hereby release them from any liability on account of injuries sustained by the player while participating in any activities. I give consent for the above player to be photographed, videotaped or filmed while participating in any soccer activities and the resulting photos / film to be used by UC Premier and its agents and employees for educational and promotional purposes. I have read and understand the above. I also acknowledge that players will be notified of team selection via the team manager or head coach after the assessment and accept that the decision of UC Premier will be final.

NOTE: You will receive an email confirmation, please print/sign and bring with you to the location indicated by the UC Premier Representative who contacts you.

AOL users

AOL Users have been experiencing issues with receiving confirmation notice, but rest assured your pre-registration has been received.

Comments

This field is for validation purposes and should be left unchanged.

UC PREMIER Competitive Assessment Form

ASSESSMENT WAIVER\REGISTRATION FORM

PLAYER INFORMATION

PARENT/GUARDIAN INFORMATION