1. Healthcare

Office Use Only SOCCER APPLICATION Date Received_____________ Pmt Type & Amt ___________ Received by_______________ Spring 2015 Registra on Fees: Deadline for guaranteed placement is February 4, 2015. Players must be 4 years old by July 31, 2014 to be eligi‐
ble to play. Ages 4‐7 (as of 7/31/14) $60 + $15 Op onal Volunteer fee Ages 8‐13 (as of 7/31/14) $70 + $15 Op onal Volunteer fee Ages 14‐18 (as of 7/31/14) $80 + $15 Op onal Volunteer fee To register online for DASC Spring 2015 season or other programs log onto: www.dakotaalliancesoccer.com No refunds a er February 11, 2015 Dakota Alliance Soccer Club DASC is eligible for a limited number of United Way Connec ng Kids Cer ficates for use by families presen ng documenta on of free/reduced school lunches. UW Cer ficates can be used once in a calendar year and only for grades K through 8th. 401 West 39th Street, Sioux Falls, SD 57105 Phone 332‐5911 Fax 332‐0278 __________exp date________
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A Birth Cer ficate is required with registra on for any player who is new to DASC or has not yet provided a copy of their BC to DASC. See back of applica on for informa on. Player’s Informa on Gender Date of Age as of School player a ends during (M/F) Birth 7/31/2014 Spring 2015 Volunteer? yes/no If yes, please indi‐ cate what you will If you are not do: 1. Coach 2. Assistant Coach volunteering, there is an addi‐ 3, Fields 4. Tournaments onal $15 fee Total per child Registra on Fee Last Name First Name 1 2 3 4 Sponsor one player ($60‐$80) or contribute to help players who cannot afford the full registra on fee Elementary School nearest (geographically) the player(s) Father's Informa on Last Name First Name Address City, State, Zip Home Phone Work Phone Employer E‐mail (print clearly) Custodial Parent Cell Mother's Informa
Last Name First Name Address City, State, Zip Home Phone Work Phone Employer E‐mail (print clearly) Total Enclosed on Custodial Parent Cell I require Handicapped Accessible Viewing Addi onal Spring registra on informa on on the back side of this registra on. Please read and complete. Birth Cer ficate Requirements for Spring 2015 Registra on As of Fall 2009 the US Soccer Federa on has mandated that every player’s birth date be verified with a COPY of their Birth Cer ficate. The Birth Cer ficate must accompany the registra on for players who are new to DASC or have not yet provided a copy to DASC. Proof of age shall consist of a State Cer fied Birth Cer ficate, a Uniformed Services Iden fica on and Privilege Card (DD form 1173) issued by the uniformed services of the United States, birth registra on issued by an appropriate government agency, drivers license, Board of Health records, passports, alien registra on card issued by the US Government, or cer ficate issued by the Immigra on and Naturaliza‐
on Service a es ng to age or cer fica on of an American ci zen born abroad issued by an appropriate government agency. DAKO‐
TA ALLIANCE SOCCER CLUB CANNOT ACCEPT HOSPITAL CERTIFICATES OR BAPTISMAL RECORDS. A player cannot be registered un l the birth date has been verified with the Birth Cer ficate. How Teams are Determined for the Spring Season: If the player played on a Fall 2014 team, he/she will be placed on that same team for the Spring 2015 season if the player is registered by the registra on deadline. Teams stay together for the Fall 2014 and Spring 2015 seasons. If the player did not play in the Fall 2014 season he/she will be placed on a team in the player’s geographical area if the player is registered early. Games are tenta vely set to begin play early April, 2015 and finish before Memorial Day weekend. Games will be played on either a Monday, Tuesday, or Thursday evening or during the day on Saturday with the majority of the games being played on Saturday. Deadline for guaranteed placement is February 4, 2015. Important—Please read the following and sign below: I, the parent/legal guardian of the named registrant(s), a minor(s), agree that I will abide by the rules of the USYSA, its affiliated organiza ons and sponsors. Recognizing the possibility of physical injury associated with soccer and in considera on of the USYSA ac ng as the registrant(s) for its soccer programs and ac vi es (the “Programs”), I hereby release, discharge, and/or otherwise indemnify the USYSA, its affiliated organiza ons and sponsors, their employees and associated personnel, including owners of the fields and facili es u lized for the programs, against any claim by or on behalf of the registrant(s) as a result of the registrant(s) par cipa on in the programs and/or being transported to or from the same. In addi on, as a parent or legal guardian of the named registrant(s), I hereby give my con‐
sent for emergency medical care prescribed by a licensed Doctor of Medicine or Doctor of Den stry. This care my be given under whatever condi ons are necessary to preserve the life or well being of my dependent. By signing this form, I agree and consent that both SDSSA and its member associa ons have my permission to use any image, photograph, video clip, or other similar image, in any media format, of either myself or my child, provided (1) the image is taken while I am, (or my child is) a player or par cipant in one of the various ac vi‐
es, events, and compe ons sponsored by SDSSA or its member associa ons or as otherwise allowed by law, and (2) the image is used for one or more of the follow‐
ing purposes: media coverage of soccer ac vi es, SDSSA Website use, SDSSA promo onal materials, program books, video presenta ons and for similar purposes relat‐
ed to the ac vi es of SDSSA or its member associa ons. I further release both SDSSA and its member associa ons from any liability for any adverse results which may result from the use of the above named photograph(s) or media images in the manner described. To opt out check here ________. I do agree that any email address I provide may be used by the Local and State Soccer Associa on, US Youth Soccer and any of their assigns to provide me with infor‐
ma on about their programs and sponsors. To opt out check here ________. I cer fy that everything on this applica on is correct, to the best of my knowledge. X________________________________________________________________ The Sioux Falls Catholic School System neither endorses nor sponsors the organiza on or ac vity represented in this document. The distribu on of this material is provided as a community service. Programs available thru DASC: Recrea onal Soccer, Academy, Compe
ve, XTRA KIXX, Camps/Clinics, Total Futbol, SoccrerNas cs, Joga, Toca, Sanford POWER, and Monday Night Futbol (U15‐U18) For more informa on log onto: www.dakotaalliancesoccer.com