F.C. Mirage » Tryouts

2019 TRYOUTS – COMING SOON

FC Mirage Soccer Tryout Registration Form

Player's Name *
Date of Birth *
Gender *
MaleFemale
Phone
Address
Street AddressApt, Suite, Bldg. (optional)CityState / Province / RegionPostal / Zip CodeCountry

Mother Information

Mother's Name
Cell Phone
Email
Work Phone

Father Information

Father's Name
Cell Phone
Email
Work Phone

Emergency Contact Information

Emergency Contact Name
Emergency Contact Phone

Previous Soccer Experience

Positions Played
Previous Clubs
Does the player have any disabilities, handicaps, present injuries, or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical illness that might affect his or her participation in the sport of
YesNo
If so, please explain
Participation Agreement & Liability Release - Initial Here *Consent and Release: I acknowledge that soccer is a contact sport, which involves the possible risk of injury. I consent to my child’s participation in F.C. Mirage (FCM) soccer program and tryouts. I, individually, and on behalf of my child, do hereby release and forever discharge FCM, its shareholders, officers, members, coaches, directors, agents and representatives from any and all liability of whatever nature relating to or in any matter arising out of my child’s participation in any and all programs offered by the FCM. I agree to hold the FCM harmless and indemnify it for any damages, which may be sustained in connection with our association or with participation in the FCM soccer program. I understand that personal injuries can occur before, during, and after soccer games or practices by reason of field preparation and conditions, equipment conditions, and contact with participants, FCM personnel and spectators. This release shall apply to any personal injury or other loss whether or not reasonably anticipated, expected, or contemplated at this time. This release is indemnification shall be binding upon my personal representatives, heirs and assigns. By filling out and submitting the below registration form, you give full consent and release for your child to participate in F.C. Mirage soccer tryouts.

Verification

To confirm Tryout Submission please enter any two digits with no spaces (Example: 12) *
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Questions? Please contact us via e-mail at the address below

E-Mail: fcmirage2012@gmail.com