Charlotte United Futbol Club Challenge Player Registration

Office Use Only!
Received
Charlotte United Futbol Club
Challenge Player Registration
Payment/Check #
Please include this sheet with the required attachments and bring to the
appropriate player registration fair or mail to the club at:
Charlotte United Futbol Club
PO Box 49287
Charlotte, NC 28277
Amount
Photo
Deadline for receipt of all forms, along with the NON-REFUNDABLE $275.00 deposit is
June 1, 2009. Note: Non-refundable $275.00 can be paid online and is part of the club
dues. Players will be considered for team assignments ONLY upon receipt of information
and deposit - NO EXCEPTIONS!!!
Players Name ____________________________________________________________
Address ________________________________________________________________
(Street)
(City)
(State)
(Zip Code)
Phone Number _____________________ Age Group U-______ Male ____ Female _____
Email Address____________________________________________________________
Players are required to provide the following information to register for a team. All forms
are included in this packet and available online on the Charlotte United website.
Non-Refundable $275 Deposit
Receipt from online payment or check payable to CUFC
Medical Waiver – NOTARY NOT REQUIRED
Copy of Birth Certificate/Passport
Foreign Born Players – See attached requirements
Interstate Release Form – Players Residing in SC
Returning to
CUFC
New to
CUFC
Yes
Yes
2 Copies
2 Copies
Yes
Yes
Yes
Yes
(SC only)
(SC only)
Yes
Yes
No black & white, hats or shades - Must be on photo quality
paper. Write name on the back
Yes
Yes
Uniform Order Form
Yes
Yes
Complete, sign & include with a $10.00 check or money order
payable to SCYSA. You will not be registered until this is done.
If you live in another state, please call our office.
Financial Contract
1" x 1" Color FACE ONLY Photo
2009-10 Charlotte United Financial Contract
PLAYERS NAME:____________________________________________________
PARENTS NAME:_______________________________________________
TEAM NAME:__________________________________________________
Please initial each box confirming you have read and understand each item
PLAYER’S CLUB DUES
1. A player’s club dues are determined by their team assignment. Club dues do
not include team fees, which include but are not limited to: referee fees,
tournament’ entry fees, reasonable coach’s travel expenses and individual
travel or any other reasonable expenses incurred by the team as determined
by each individual team. _______
2. All dues payments are to be made in accordance with the terms on the
payment sheet. _______
3. Any payment received 30 days after its due date shall be past due and
may result in surrender of a player’s membership card. Players will not
be allowed to practice or play until the membership card is reinstated. In
addition to any outstanding fees due, a $50.00 reinstatement charge shall be
required to reinstate the player’s card. _______
PARENT’S RESPONSIBILITES – Please initial each box
In accordance with established policies of Charlotte United Futbol Club and its Board
of Directors, a parent or legal guardian of each player agrees to the following
financial obligations.
1. By your signature below, you acknowledge that you have read and
understand the player’s club dues, payment schedule, and that you are
financially responsible for the dues as stated for the entire playing year*.
Refunds,(less the $400.00 non refundable service charge) will only be issued
for a season ending injury or for moving out of the area. ________
2. Your payment schedule must be met unless the Treasurer has approved, in
writing in advance a written request for a different payment schedule.
Statements will not be mailed out in advance of any due date. _______
3. Financial Aid is available for those families truly in need. Please contact the
CUFC offices for an application that must be submitted with your child’s forms
by 6/6/09. Keep in mind that copies of tax statements and pay stubs will be
required with your application for financial aid – NO EXCEPTIONS.
______________________________
Parent Signature
____________________________
CUFC Treasurer’s Signature
______________________________
Print Parent’s Name
*Please note: Upon commitment to a team, you are financially responsible for all
Club fees as stated for the entire year. Beginning August 1, 2009 players will not be
officially released from CUFC until all Club fees are paid in full and team fees are up
to date at the time of the request.
Charlotte United FC
2009 - 10 Club Fees
Boys Classic
Age
U11
U12
U13
U14
U14
U14
U15
U15
U15
U16
U16
U16
U17
U17
U17
U18
U18
U18
Division
All
All
All
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Total Fee
$995
$995
$1,350
$1,450
$1,350
$1,350
$1,350
$1,100
$1,000
$1,350
$1,100
$1,000
$1,350
$1,100
$700
$1,350
$1,100
$700
June 1, 2009 *
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
July 1, 2009
-
Age
U11
U12
U13
U14
U14
U14
U15
U15
U15
U16
U16
U16
U17
U17
U17
U18
U18
U18
Division
All
All
All
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Premier
1st
2nd
Total Fee
$995
$995
$1,350
$1,450
$1,350
$1,350
$1,350
$1,100
$1,000
$1,350
$1,100
$1,000
$1,350
$1,100
$700
$1,350
$1,100
$700
June 1, 2009 *
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
$400
July 1, 2009
$250
$175
$150
$250
$175
$150
$250
$175
$75
$250
$175
$75
Age
All
Division
All
Total Fee
$700
June 1, 2009 *
$275
July 1, 2009
-
Aug. 1, 2009
$300
$300
$400
$400
$400
$400
$475
$400
$400
$475
$400
$400
$475
$400
$200
$475
$400
$200
Sept. 1, 2009
-
Oct. 1, 2009
$295
$295
$350
$350
$350
$350
$475
$300
$200
$475
$300
$200
$475
$300
$100
$475
$300
$100
Nov. 1, 2009
-
Dec. 1, 2009
$200
$300
$200
$200
-
Sept. 1, 2009
$250
$175
$150
$250
$175
$150
$250
$175
$75
$250
$175
$75
Oct. 1, 2009
$295
$295
$350
$350
$350
$350
$200
$175
$150
$200
$175
$150
$200
$175
$75
$200
$175
$75
Nov. 1, 2009
-
Dec. 1, 2009
$200
$300
$200
$200
Sept. 1, 2009
-
Oct. 1, 2009
-
Nov. 1, 2009
-
Dec. 1, 2009
$200
Girls Classic
Aug. 1, 2009
$300
$300
$400
$400
$400
$400
$250
$175
$150
$250
$175
$150
$250
$175
$75
$250
$175
$75
Challenge
* Non-Refundable Deposit
Aug. 1, 2009
$225
MEDICAL WAIVER – INSTRUCTIONS
North Carolina Youth Soccer Association requires each player to have a complete and
notarized medical waiver. It is very important for each waiver to be completed correctly.
PLEASE DO NOT LEAVE ANY BLANK SPACES. – NOTE- ONLY ONE PARENT NEEDS TO SIGN
Please note the following:
___
DO NOT FILL IN THE TEAM NAME OR JERSEY NUMBER!!!!
___
Use player’s given name as printed on the birth certificate. Include middle
initial. No nicknames please.
___
Birth date
___
Complete address of player
___
Emergency contact is important. This individual will be contacted if
parent/guardian is not available
___
Date of tetanus (month/year). Or indicate “current”
___
Comment regarding medications taken. If none, write NONE
___
Complete allergy information. If no allergies, write N/A
___
List unusual health information (asthma, epilepsy, etc.). Write N/A if none
___
Information about insurance. If player is uninsured, write none.
Medical waivers will be with the team AT ALL TIMES. The waiver will be used only
when an injury occurs and the player’s parent/guardian is not present.
PLAYER PHOTO INFORMATION
•
•
•
•
In order for your child to have a player pass, you must provide a 1” X 1” full faced
head shot photo. Passport photos or school photos are the best.
Must be a color photo on photo quality paper. Please don’t bring us black & white
photos on regular copy paper!!! We will not accept them.
No sunglasses or hats, please.
PRINT player’s name on the back.
This photo MUST accompany your registration paperwork or the child cannot be
registered. This is a mandate by the NCYSA that all player passes have a photo.
FINANCIAL INFORMATION
Upon commitment to a team, you are financially responsible for all Club fees
as stated for the entire playing year. Beginning August 1, 2009 players will not be officially
released from CUFC unless all Club fees are paid in full and team fees are up to date at the
time of the request.
Medical Consent / Waiver of Liability and Release
( To be given to your local association )
NCYSA
NCYSA Policy #
Excess policy to any valid and collectible
insurance. If there is no primary
insurance on a player, this policy is
primary after the deductible.
PO Box 29308
Greensboro, NC 27429
336.856.7529
Player First Name
M Initial
Last Name
( AS APPEARS ON BIRTH CERTIFICATE)
Full Team Name
[ ] Academy
[ ] Challenge
Birth Date
[ ] Classic
Jersey #
[ ] Recreation
Level
[ ] Male
[ ] Female
Sex
Address of Player
City
State
Zip
Parent/Legal Guardian Full Name
Home Phone
Work Phone
Cell Phone
Additional Person to Contact in an Emergency
Address
Home Phone
Cell Phone
Date of Last Tetanus Shot
Medications now being taken
Player is Allergic to these Medications and Substances
List any Unusual Health Information
I (we), the undersigned, residing in the county of
, state of _________, the parents/legal guardian of the above
Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned
soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association.
I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated
with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the “ Programs”), we hereby jointly and severally release,
discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and
facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registrant’s participation in the Programs and/or being transported to or from the
same, which transportation we hereby authorize.
I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named
individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above
Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips
sponsored by or in conjunction with the Programs.
In addition, I (we) do hereby authorize any one of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain
consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment,
and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice.
The undersigned have read and fully understand and agree to the foregoing.
Insurance Information:
Name of Insurance Company:
ID Number:
Parent/Legal Guardian Signature
Confirmation Number:
Original (Team)
Copy (Association)
Medical Consent / Waiver of Liability and Release
( To be given to your local association )
NCYSA
NCYSA Policy #
Excess policy to any valid and collectible
insurance. If there is no primary
insurance on a player, this policy is
primary after the deductible.
PO Box 29308
Greensboro, NC 27429
336.856.7529
Player First Name
M Initial
Last Name
( AS APPEARS ON BIRTH CERTIFICATE)
Full Team Name
[ ] Academy
[ ] Challenge
Birth Date
[ ] Classic
Jersey #
[ ] Recreation
Level
[ ] Male
[ ] Female
Sex
Address of Player
City
State
Zip
Parent/Legal Guardian Full Name
Home Phone
Work Phone
Cell Phone
Additional Person to Contact in an Emergency
Address
Home Phone
Cell Phone
Date of Last Tetanus Shot
Medications now being taken
Player is Allergic to these Medications and Substances
List any Unusual Health Information
I (we), the undersigned, residing in the county of
, state of _________, the parents/legal guardian of the above
Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned
soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association.
I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated
with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the “ Programs”), we hereby jointly and severally release,
discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and
facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registrant’s participation in the Programs and/or being transported to or from the
same, which transportation we hereby authorize.
I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named
individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above
Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips
sponsored by or in conjunction with the Programs.
In addition, I (we) do hereby authorize any one of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain
consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment,
and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice.
The undersigned have read and fully understand and agree to the foregoing.
Insurance Information:
Name of Insurance Company:
ID Number:
Parent/Legal Guardian Signature
Confirmation Number:
Original (Team)
Copy (Association)
**** Important Information for All Players Born Outside ****
Of the United States
The following items are required as part of the registration process for all players who were born outside of
the United States.
Please note: if a player provides a birth certificate printed in a foreign language, an English translation copy
must submitted
Players moving from Challenge to Classic MUST provide a new copy of their Birth Certificate or Passport
for the registration process
For All International Players: Origin of Birth/Proof of Age must be provided in order for a player
to be registered:
Players Under 12 years of Age:
- Copy of birth certificate (if in foreign language, English translation required) -or- Copy of Passport
th
- Must provide proof that child entered the country prior to their 12 birthday Documents considered proof of entry – CHOOSE ONE:
- School Records/Most recent report card
- Immunization Record
- Doctor’s Record
- Prior registration history with the State Association
- Immigration Record
- State-Issued ID Card
Players Age 12 to 16 Years of Age:
- Copy of birth certificate (if in foreign language, English translation required) -or- Copy of Passport
- Must complete an “International Clearance Waiver” form
- Form must be completely filled out & signed by both player & parent/guardian
* If player has previously submitted an International Clearance Waiver form, it is
not necessary to complete again
Players Age 17 Years of Age and Older:
- Copy of birth certificate (if in foreign language, English translation required) -or- Copy of Passport
- Must complete an “International Clearance Request” form
- Form must be completely filled out & signed by both player & parent/guardian
* If player has previously submitted an International Clearance Request form, it is
not necessary to complete again
- This form needs to be submitted immediately, as the processing time is a minimum of
30 days - Player may practice but NOT play in an official capacity until permission
Is received from the US Soccer Federation
CHARLOTTE UNITED FUTBOL CLUB,INC
UNIFORM ORDER FORM
Player Name:______________________________
Team: _____________________________
CIRCLE SIZE REQUIRED
Shirt size (girls): XXS, XS, AS, AM, AL, AXL
Shirt size (boys): YS, YM, YL, YXL, AS, AM, AL, AXL
CIRCLE SIZE REQUIRED
Short size: (girls) XXS, XS, AS, AM, AL, AXL
Short size: (boys) YS, YM, YL, YXL, AS, AM, AL, AXL