Women's GSA Pro23 - 2022 TRIAL REGISTRATION FORM

GSA WOMEN'S PRO 23 -2022 OPEN TRIALS

Registration Form
Grove Soccer Academy is pleased to host the 2022 Open Tryouts giving aspiring players the opportunity to earn a roster spot as the coaching staff builds the squad for the 2022 season. The GSA staff will be evaluating players for the First Team, Reserve Team, and the U19 Development Team.

WHEN

May 08, 2022

10 am - 12 pm

Check-in 9:30 am

WHERE

River City Sportsplex

13030 Genito Rd, Midlothian, VA

23112, United States

Check-in Field 4

REGISTRATION FEE

Early Registration - $40 on or before May 1, 2022

Full Price- $50 on or after May 2, 2021.

Registration fees are non-refundable and must be paid in advance, online only.

At the end of the registration form, you will be taken to the payment portal. Once you have completed the registration payment you will receive a confirmation email to show at check-in.

Please contact the GSA at info@grovesocceracademy.com if you have any questions throughout the process.
PARTICIPANT INFORMATION:
Player Name *

First Name Last Name
Birth Date *

Month Day Year
Profile Picture
What position do you play?
What clubs have you played for? (Please include years played at each club and league)
What college did you play for? (Please include the years attended)
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code Country
E-mail *
example@example.com
Phone Number *

Area Code Phone Number
How did you find about the Grove Soccer Academy?
Age? *

Under 18 18 or Older
PARENT/GUARDIAN INFORMATION:

If under 18 please complete the Parent/ Guardian Information
Parent/Guardian Name

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
Parent/Guardian Name

First Name Last Name
Phone Number

Area Code Phone Number
E-mail
example@example.com
EMERGENCY CONTACT INFORMATION

In an emergency please contact:
Primary Emergency Contact *

First Name Last Name
Primary Emergency Contact Relationship to Player *
Primary Emergency Contact Home Number *

Area Code Phone Number
Primary Emergency Contact Work Number

Area Code Phone Number
Secondary Emergency Contact

First Name Last Name
Secondary Emergency Contact Relationship to Player
Secondary Emergency Contact Home Number

Area Code Phone Number
Secondary Emergency Contact Work Number

Area Code Phone Number
INSURANCE INFORMATION

If said participant is covered by any insurance, please complete the following.
Medical Insurance Company
Medical Insurance Group Number
Medical Insurance Policy Number
Medical Insurance Policy Holder
Medical Insurance Phone Number
PHYSICIAN INFORMATION
Physician's Name

First Name Last Name
Hospital of Choice
Physician's Home Phone Number

Area Code Phone Number
Physician's Phone Number

Area Code Phone Number
MEDICAL HISTORY

If the answer to any of the following questions (below), is yes, please describe the problem and its implications for proper first aid treatment within the registration.
Does the player have any allergies that we need to be made aware of? *
If yes, please describe the problem and its implications for proper first aid treatment within the registration.
Does the player have any medical conditions that we need to be made aware of? *
If yes, please describe the problem and its implications for proper first aid treatment within the registration.
WAIVER
ASSUMPTION AND ACKNOWLEDGEMENT OF RISK AND RELEASE OF LIABILITY AGREEMENT

By submitting this form I, the participant or parent/guardian of the above listed minor (if participant is under the age of 18), acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue The Grove Academy, or GSA, its directors, officers, employees, coaches, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the events, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the participant as a result of the participant's participation in any Grove Soccer Academy event or program and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize.

PHOTO/ VIDEO RELEASE

I hereby voluntarily and without compensation authorize visual images and/or voice recordings to be made of the participant by or on behalf of the Grove Soccer Academy their sponsoring entities during the program. I also authorize the foregoing entities and their assigns to reproduce, modify, publicize, broadcast, and display any such visual images or voice recordings, with or without my name, without notice or payment of any royalty, fee, or other compensation of any character to me for the use of my image, name or voice.

MEDICAL RELEASE/ CONSENT

I hereby give my consent to have an athletic trainer, trained first aid parent, coach and/or doctor of medicine or dentistry or associated personnel to provide the participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees.

IMPORTANT: RETURN TO PLAY AND GSA CONCUSSION POLICY:

In the event that a participant received any kind of injury, the participant will be monitored closely, and the GSA reserves the right to remove a participant from participation in any session if symptoms are too severe to continue.

PLEASE NOTE: IF DIAGNOSED WITH ANY TBI (TRAUMATIC BRAIN INJURY), THE PARTICIPANT WILL NOT BE ABLE TO RETURN TO PLAY UNTIL A LETTER IS RECEIVED BY GSU FROM A DOCTOR OR MEDICAL PRACTITIONER THAT FULLY CLEARS THE ATHLETE FOR A RETURN TO PARTICIPATION.

I acknowledge that I have read the foregoing and I fully understand the contents.
Participant Name *

First Name Last Name
Parent Name

First Name Last Name
Do you consent? *
Date of Consent *

Month Day Year
Date
Participant or Parent/ Guardian Signature *

Clear
COMMUNICABLE DISEASE RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FOR TRIALISTS
In consideration for being allowed to participate as a trialist in events and activities related to the Grove Soccer Academy including activities organized by or on behalf of my club and the activities incidental thereto (e.g., activities associates with travel with my club) (collectively, “Soccer Activities”), I, the undersigned, acknowledge and agree as follows:

There is an ongoing pandemic of COVID-19, a contagious virus which may cause severe illness, other adverse medical reactions, quarantine requirements, transmission to friends and/or family, and/or death in addition to other adverse results, the scope of which may not be fully understood given that COVID-19 is a novel virus and has not yet been fully evaluated by the medical community (“Virus Risks”). COVID-19 is believed to spread mainly from person-to-person contact, aerosol droplets, and also through surfaces, and it may be spread by individuals who are pre-symptomatic or asymptomatic.

My participation in Soccer Activities as a trialist will substantially increase my risk of exposure to COVID-19, given that, by their nature, Soccer Activities involve person-to-person contact. I agree to assume full responsibility for any resulting Virus Risks, whether they be known or unknown.

I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS GROVE SOCCER ACADEMY AND THEIR AFFILIATES (“LEAGUES”) IN ADDITION TO EACH OF THE LEAGUES’ CLUBS AND THEIR RESPECTIVE AFFILIATES, and each of their respective directors, officers, officials, agents and/or employees, associated personnel, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (“Releasees”), from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY OR DEATH that I or a third party may suffer as a result of the Virus Risks or the Soccer Activities, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Participant Name *

First Name Last Name
Parent Name

First Name Last Name
Do you consent? *
Date of Consent *

Month Day Year
Date
Participant or Parent/ Guardian Signature *

Clear
TRYOUT REGISTRATION FEE
Registration fees are non-refundable and must be paid in advance, online only. No checks or cash will be accepted.
Questions or Comments
Please complete registration payment below in order to submit the form.
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Tryout Registration Fee $ 40.00

Total $ 0.00

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GSA WOMEN'S PRO 23 -2022 OPEN TRIALS

PARTICIPANT INFORMATION:

PARENT/GUARDIAN INFORMATION:

EMERGENCY CONTACT INFORMATION

INSURANCE INFORMATION

PHYSICIAN INFORMATION

MEDICAL HISTORY

WAIVER

COMMUNICABLE DISEASE RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT FOR TRIALISTS

TRYOUT REGISTRATION FEE