EmailMe Form - Ohio North Soccer - Out of State Permission

*USYSA Rule 201 requires that a youth player register each seasonal year in the State Association in which he/she resides with their parent(s)/guardian(s). A youth player wishing to participate with another team from another state in which they reside must receive written permission from both state associations prior to participation.

This form must be completed by all players requesting permission to play with a state association other than the state in which they reside as well as by any player moving from one state association to another during the Seasonal Year.

Seasonal Year *

A Seasonal Year is September 1st thru August 31st

Player Name *

First Last

Player D.O.B. *

MM / DD / YYYY

Ohio North Member ID

Ohio North Member ID is unique to each registrant. If you do not know, please leave blank.

Gender *

Birth Certificate Upload *

Please upload copy of player birth certificate PDF, JPG, WORD docs are accepted.

Photo Upload *

Current player photo: used to create player profile and/or player pass (jpg. format)

Player Street Address *

Player City *

State *

Player Zip Code *

Guardian Name *

First Last

Guardian Email *

Confirm Email *

Guardian Phone # *

### - ### - ####

Please include the phone number where you can best be reached during Ohio North office hours, 8:30-4 Monday through Friday.

Team Information

Provide information for the team player is requesting to be carded with

Club Name: *

Club Name of the team player will be playing on.

Team Name: *

Team Name player will be playing on.

Age Division *

Age division of the team that the player will be playing on.

Playing League: *

League Name that the team with be playing in.

Accepting State: *

State player wishes to particpate in.
If 'Other' is selected, designate below.

Other State

Only Required if state was not listed in drop down above.

__________________________________________

WAIVER of LIABILITY

I/We, the undersigned do voluntarily give permission for our child to participate in all US Youth Soccer and Ohio North activities. We do hereby assume full responsibility for any risk of bodily injury, personal injury or mental injury or death due to our child’s participation in any such activities and the necessary travel to and from any activity site. We also further hereby assume full responsibility for all lost, stolen, or damaged personal property and will not hold the US Youth Soccer/Ohio North or its/their employees responsible for said loss or damage to personal property. The undersigned further release, waive, discharge, indemnify and covenant not to sue US Youth Soccer and Ohio North, its/their individual members, its/their employees, agents or anyone acting on its/their behalf, from all liability, arising from or by reason of any bodily injury, personal injury or mental injury, known or unknown, including death, resulting from, or to result from our child’s participation in any US Youth Soccer or Ohio North activity. We expressly agree that this release is intended to be as broad and inclusive as permitted by the laws of the State of Ohio or any other state in which my/our child may be injured, and that if any portion of this release is determined to be invalid, it is agreed that the remaining provisions of this release shall continue in full force and effect. We further state that we have fully and carefully read the above release, understand the contents of the same and sign this release voluntarily and as our own free act and deed.

*

I agree to waiver of liability.

By checking this box and submitting this e-Registration form, I acknowledge that: I am the parent/guardian authorized to consent on the player’s behalf; I have reviewed this form and the information it contains and represent that it is accurate; and I agree to submit this form electronically with the intent to be bound by its terms and conditions.

GENERAL CONSENT for MEDICAL TREATMENT

I/We hereby give my consent for (1) the administration of any treatment deemed necessary by above-named doctor, or, in the event the designated preferred practitioner is not available, by another licensed physician or dentist; and (2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the performance thereof. Facts concerning the child’s medical history, including allergies, current medications, and any other physical ailments or impairments to which the physicians should be alerted. Referenced above if/where applicable.

*

I agree to consent for medical treatment.

By checking this box and submitting this e-Registration form, I acknowledge that: I am the parent/guardian authorized to consent on the player’s behalf; I have reviewed this form and the information in contains and represent that it is accurate; and I agree to submit this form electronically with the intent to be bound by its terms and conditions.

OHIO RETURN TO PLAY LAW: CONCUSSIONS – Players 18 years of age must acknowledge

*

I have read the Ohio Department of Health Concussion Information

By checking this box and submitting this e-Registration form, I acknowledge that: I have read the Ohio Department of Health Concussion Information Sheet for Youth Sports.

OHIO NORTH PAYMENT

Payment must be sent to Ohio North for the request to be processed. NOTE: Membership with Ohio North needs to be completed annually. The annual seasonal year runs from the fall to the spring (Sept 1 - Aug 31). Players are considered new members at the start of the new seasonal year.

Out of State Permission - $21
(Registration will not be processed without receipt of payment)

Registration/Out of State Fees *

Player Registration $21

Out of State Registration Request will not be processed without receipt of payment.

Payment will be sent via: *

Charge Card through Authorize.net: I will pay with a Credit Card through Authorize.net right now. (please note that after form is submitted, you will automatically be redirected to a payment screen.)

IMPORTANT

Please only hit the "SUBMIT" button once. Multiple clicks can make payments to process multiple times.