Please print legibly. Please supply all information that pertains to you. First and last names, mailing address, city, state, zip code and birth date are required to register. You may decline to give your Social Security number. Welcome to NCASA!
|Social Security Number
|Name (first, mi, last)||Birth Date (mm/dd/yy)||Sex (check one)
|Street Address, PO Box or RR
(__ __ __) __ __ __ - __ __ __ __
(__ __ __) __ __ __ - __ __ __ __ / __ __ __ __
|Preferred language (check
coach/captain assistant player
|Are you a U.S.
|If you are not a U.S. citizen, print the name of your nation.||Check here
if you have a US Amateur player pass. (You will not be issued a new pass
if you check the blank.)
|Email Address, if you have
You MUST READ AND SIGN THE INSURANCE WAIVER BELOW.
Commercial General Liability
Policy Number MOLO20669
This endorsement changes the policy. Please
read it carefully.
U.S. Amateur Soccer Association
WAIVER AND RELEASE OF LIABILITY
In consideration of being allowed to participate
in any way in the U.S. Amateur Soccer Association athletics/sports program and
related events and activities, the undersigned:
1. Agrees that prior to participating, he or she will inspect the facilities and equipment to be used and, if he or she believes anything is unsafe, they will immediately advise their coach or supervisor of such condition(s) and refuse to participate;
2. Acknowledge and fully understand that the participant will be engaging in activities that involve risk or serious injury, including permanent disability and death, and severe social and economic losses which might result not only from their own actions, inactions or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, that there may be other risks not known to us or not reasonably foreseeable at this time;
3. Assume all the foregoing risks and accept personal responsibility for the damages following such injury, permanent disability or death;
4. Release, waive, discharge and covenant not to sue the U.S. Amateur Soccer Association, the North Carolina Amateur Soccer Association, its affiliated leagues, its affiliated clubs, their respective administrators, directors, agents, coaches and other employees of the organization, other participants, sponsoring agencies, sponsors, advertisers and, if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as "releasees", from demands, losses or damages on account of injury, including death or damage to property, accused or alleged to be caused in whole or in part by the negligence of the releasee or other wise.
THE UNDERSIGNED HAS READ THE ABOVE WAIVER AND RELEASE, UNDERSTANDS THAT HE OR SHE HAS GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGNS IT VOLUNTARILY.
(Imprima su nombre) (Firma) (Fecha)
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