PayPal Receipt ID.   

Do not continue with out paying on Paypal first.

Preferred Coach:   No Preference. 

Child’s Last Name:  First Name:

Child’s Date of Birth:                    dd/mo/yyyy    Child’s Gender: Male:   Female:

Address:     

City:     Zip Code:  

Primary Phone Number:    Alternate Number:  

Primary E-mail:    

Father’s Name:   

Mother’s Name:  

Would you like information about volunteering?:

If you paid for a uniform, Please Select Size: YXS YS YM YL AS AM AL

IMPORTANT

I, the parent/guardian of the above-named player, a minor, agree that I and the player will abide by the rules and regulations of the USYSA, its affiliated organizations and its sponsors (“USYSA Parties”), the conditions stated above and the PUEBLO RANGERS CODE OF CONDUCT. Players registering with the Pueblo Rangers Soccer Club certify that they are not currently registered with any other USYSA organization and may not play for any other USYSA organization for the duration of the current season.  In consideration of the player’s participation in the soccer programs and activities of the USYSA Parties (the “Programs”), I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player’s participation in the programs including, without limitation, players transportation to/from any Program, which transportation is hereby authorized. I further grant the USYSA Parties the right to use the player’s name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player’s status as a participant in the Programs.

Consent For Medical Treatment (Minor): As the parent or legal guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medical or Doctor of Dentistry.  This care may be given under whatever conditions are necessary to preserve the life, limb and well-being of my dependent.

I agree to the above and further state that all information that I have provided is true and accurate. (Type "yes" in this box      )

DO NOT SUBMIT MORE THAN ONE REGISTRATION PER PLAYER !