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HSU 6v6 Soccer Tournament 2012 6v6 Soccer Tournament will take place March 31st 2012 at Humboldt State University. This is an open tournament allowing any player the opportunity to compete. Guaranteed AT LEAST 3 GAMES. There will be a Men’s and Women’s Bracket. (No Co-Ed)

March 31st 2012

(Registration MUST be recieved by March 23rd 2012) ~ Full Payment, Team Application, and all Waivers ~

Men’s & Women’s 6v6 Tournament (5 Field Players + 1 Goalkeeper)

The cost is $100 per team To make communication as easy as possible, each team will have a Captain. This person will act as the go between. To register, the Team Application and FULL payment is required. Each player must fill out a copy of the Waiver and the Team Captain must return all forms together as a complete team packet to:

HSU Student Financial Services 1 Harpst Street Arcata, C.A. 95521 (Make checks payable to Humboldt State University)

AND, send conformation EMAIL to Roland Demombynes

Check In:

Team “Check In” will be at 8:30am on March 31st. “Check In” will be at the New College Creek Soccer Field. Games will be at College Creek & Redwood Bowl

Questions?

Contact Roland Demombynes at rng4@humboldt.edu. (206)384-5530

Check out www.hsujacks.com for all the latest news about our program!


Team Application Captains’s Name:

Other Teammates:

Team Name: Phone: Email: ASSUMPTION OF RISK/HEALTH STATEMENT/LIABILITY WAIVER NOTICE: This waiver is a contract with legal consequences. Read it carefully before signing! If there are any questions concerning this document, contact the sport camp coordinator. In consideration of my son/daughter to participate in the Soccer Sport Camp, I hereby freely agree to make the following contractual agreements: In agreeing to allow my son/daughter to participate in the Soccer Sport Camp at Humboldt State University, I am aware and knowledgeable of the risks of this activity, and other risks and dangers which may occur, including but not limited to hazards of travel, acts of God, accident, illness, physical and/or psychological injury, property loss, temporary or permanent disability, or even death. I understand and agree that my son/daughter may be in situations that may arise during an activity which may be beyond control. I fully realize the dangers of my son/daughter participating in an activity of this type and voluntarily assume all the risks associated with such participation. In consideration of my son/daughter’s acceptance as a participant in such sport camp, I hereby release, forever discharge and agree to hold harmless the State of California, California State University, Humboldt State University, Redwood Conference Center, Lumberjack Enterprises, its offi cers, employees and agents from any and all liability, claims, suits or damages, including attorney’s fees resulting from my son/daughter’s participation in the sport camp. This contract shall serve to indemnify the above named parties should the same be liable or found negligent as a result of any court action arising from my son/daughter’s participation in the Soccer Sport Camp. I HAVE READ AND UNDERSTAND (INITIAL HERE) _____ I agree that it is my sole responsibility to be familiar with the physical and/or mental demands associated with the above named camp. With these demands in mind, to my knowledge, my son/daughter, does not have a physical or medical condition which would endanger him/her or others due to his/her participation in this activity, or would interfere with his/her ability to participate in the activity. I understand that the Soccer Sport Camp at Humboldt State University has not made, nor will make any investigation into the participant’s physical fi tness or the ability of the participant to participate in the activity and is relying on my representation concerning the participant’s physical and mental condition. I also agree that my son/ daughter will abide by any established rules or regulations while participating in this activity. I HAVE READ AND UNDERSTAND (INITIAL HERE) _____ I hereby declare that my son/daughter is physically capable to be a member of and participate in the Soccer Sport Camp at Humboldt State University. Furthermore, in the event of accident or illness of an emergency nature, and because I may be unable to select or approve of the required medical treatment, I do hereby authorize the organization’s offi cers, event organizers or representatives of HSU to arrange for such care as is available and necessary: and do further release and forever discharge the providers of such care and the State of California, California State University, Humboldt State University, Redwood Conference Center, Lumberjack Enterprises, its offi cers, employers and agents from any and all claims, demands and causes of action arising out of said authorization. I HAVE READ AND UNDERSTAND (INITIAL HERE) _____ Please list any physical disabilities, conditions, past injuries or any other physical limitations which could limit your son/daughter’s participation in any way. (If there is any doubt whatsoever about your child’s ability to safely participate in this activity, he/she should have a physical examination by a physician). Please list any allergies or medical alert information: _____________________________________________________________________________ ________________________________________________________________________________________________ In case of emergency notify: ___________________________________________ Home phone: ____________________ Work phone:____________________ Insurance Carrier: ________________________________________________________________ Policy #: ____________________________________________________________ I am aware that Humboldt State University does not provide medical insurance coverage and therefore take full responsibility for my child’s medical insurance and/or costs of medical treatment. I understand that all expenses, charges, or costs which might result from injury or illness are fully my responsibility. I HAVE READ AND UNDERSTAND (INITIAL HERE) _____ I have carefully read this form and understand its contents. I am aware this is an assumption of risk, a health statement and a liability waiver. It is an agreement not to sue for negligence and a contract between myself and the Soccer Sport Camp. I also hereby acknowledge that this agreement shall be governed and construed in accordance with California law and each party hereby irrevocably submits to the exclusive jurisdiction and service of process of the California courts. I further acknowledge that I am 18 years or older and am the parent or legal guardian of the participant for the benefi t of others described herein. I sign it of my own free will. I HAVE READ AND UNDERSTAND (INITIAL HERE) _____ Participant’s name_____________________________________________________ Parent/Guardian signature ___________________________ Date _______________ Participant’s signature (if over 18) _____________________ Date _______________

NST-ATH J163


HSU Soccer 6v6 Tournament