Ambassadors FC Soccer Registration Form

Soccer Registration

Ambassadors Football Club & Urban Impact Foundation
For what program are you registering?
Cup Team & Futsal Players make sure to complete second page for uploads and releases.
Player Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Gender
Parent/Guardian Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
Parent/Guardian's Email or best Email to contact
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Copy/Picture of Insurance Card

Take a picture of your medical insurance card and upload here.
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I give my consent to Ambassadors Football & Urban Impact staff and volunteers to administer over-the-counter medication to the above named child in the prescribed dosage and time increments indicated by the medication's package label:
Allergies, Health Concerns, Activity Restrictions:
Please list all that may apply
I, the parent/guardian, release Ambassadors Football, Urban Impact, league officials, member clubs, club officials, coaches, and/or anyone acting on Ambassadors Football's behalf or member clubs from any and all liabilities or responsibilities of any conditions or complications in the event of an injury to the above named player before, during, or after competition, practice league, league or club function, and/or travel to or from competition or league or club function. Recognizing the possibility of physical injury associated with soccer, I hereby release, discharge, and/or otherwise indemnify Ambassadors and Urban Impact against any claim by or behalf of the player as a result of the player's participation in the soccer programs and/or being transported to or from same, which transportation I hereby authorize. I also release Ambassadors Football and Urban Impact to use photos, audio, and video of my child for promotional materials.*
I agree to the above release
Parent/Guardian Signature

THIS SECTION ONLY IF REGISTERING FOR CUP TEAM OR FUTSAL

If not on those teams, please scroll to bottom and click SUBMIT.
Please upload your photo (FOR COMPETITIVE TEAMS ONLY)

Picture must be a close up of your face (no hats or sunglasses).
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Please upload your birth certificate/green card/resident card/etc. (FOR COMPETITIVE TEAMS ONLY)

Please upload an official document that shows your legal name and birthdate.
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FERPA Consent to Release Student Information
Student Name

First NameLast Name
Parent/Guardian requesting the release of educational records to: Urban Impact Foundation (Note: this Consent does not cover medical records held solely by Student Health Services or the Counseling Center – contact those offices for consent forms.) The only type of information that is to be released under this consent is: transcript disciplinary records, recommendations for employment or admission to other schools, all records. The information is to be released for the following purpose: family communications about school experience, employment, admission to an educational institution, academic support & planning, coordination of services. I understand the information may be released orally or in the form of copies of written records, as preferred by the requester. I have a right to inspect any written records released pursuant to this Consent (except for parents’ financial records and certain letters of recommendation for which the student waived inspection rights).I understand I may revoke this Consent upon providing written notice. I further understand that until this revocation is made, this consent shall remain in effect and educational records will continue to be provided for the specific purpose described above.*
I agree to the above release
Parent/Guardian Name

First NameLast Name
Signature
Student ID Number
Today's Date

MonthDayYear
Date
EMERGENCY MEDICAL AND LIABILITY RELEASE: My signature indicates that in the event of an emergency and in the event that: (1) a parent/legal guardian or the Authorized/Designated Individual identified above cannot be reached; or (2) immediate medical attention is necessary, I consent to have Urban Impact Foundation [UIF] staff/leaders/volunteers act in my behalf and hereby grant my permission for emergency treatment to be administered until a parent/legal guardian or the Authorized/Designated Individual identified above can be reached.I am consenting to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to his authorization.I agree not to hold Urban Impact Foundation, The Pittsburgh Public Schools, partnering organizations or any staff/leaders/volunteers, liable for any decisions for any emergency medical treatment made under this authorization or for any accident or loss to the student however caused. In addition, I do hereby release, forever discharge and agree to hold harmless Urban Impact Foundation, The Pittsburgh Public Schools, The City of Pittsburgh, partnering organizations, and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described trip or activity.*
PERMISSION TO TRANSPORT: I give UIF permission to transport my son/daughter to and from UIF programs and UIF related events, one student or household at a time. All students are required to wear masks while in vehicles.*
PROMOTIONAL RELEASE: I also release UIF to use photos, video and audio of my student in promotional materials that support Urban Impact Foundation & its programs. I understand photos may be used on billboards, bus stop advertisements, and online social media like Facebook. I release UIF from any liability connected with the use of my picture or voice recording as part of any promotional recruitment or fundraising program.*
Signature
Should be Empty:

Soccer Registration

THIS SECTION ONLY IF REGISTERING FOR CUP TEAM OR FUTSAL

FERPA Consent to Release Student Information