Arkansas State Soccer Association

State Select Program
1100 East Kiehl Avenue, Suite 3
Sherwood, Arkansas 72120
Olympic Development Program
Registration Form
Please Print

Date of Birth:_____________________ Sex: Male or Female  
Player’s Full Name:________________________________________________________ Street Address:___________________________________________________________ City:_____________________________ Zip:_____________                      
US Citizen: Yes or No Home Phone:___________________        Year of High School Graduation:___________ E-mail Address:___________________________ 
Emergency Contact:_________________________________Phone:___________________   
Current Team:__________________________ Coach:____________________________

Position:  Field Player or Goal Keeper 

Players Signature:____________________________________  Date:______________

CONSENT FOR MEDICAL TREATMENT
THIS SECTION MUST BE COMPLETED IF THE PLAYER IS TO PARTICIPATE As the parent or legal guardian of the above named player, I hereby give my 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 and well-being of my dependent. [Attached to this form should be a separate sheet of paper listing all known allergies.] 
Signature of parent/guardian______________________________  Date:___________

Parent Approval
As parent and/or guardian of the above named child, I hereby give my permission for Him/her to tryout for the ASSA Olympic Development Program.  

Signature of parent/guardian______________________________  Date:___________