AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      77452446  

 
Region Number
8
Division
10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Ava
Middle Name
A
Last Name
Arriola
Suffix
 
Area Code
 
Telephone
 
Nickname
 
Street Address
10355 Langdon Avenue
City
Mission Hills
State
California
Zip Code
91345
Mailing Address (if different from street address)
10335 langdon ave
City
Mission Hills
State
CA
Zip Code
91345
Emergency Contact (other than parent)
Adriana Arriola
Area Code
818
Emergency Telephone
939-3866
Physician Name
Dr. Montecastle
Area Code
818
Physician Telephone
365-9531
Gender
   Boy X Girl
Birthdate
5/7/2010
Age
8
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
Anthem Blue Cross
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
None
Yrs of Experience
5
Height
3.3
Weight
85
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father   X Mother      Guardian      Other

First Name
Adriana
Middle Name
 
Last Name
Arriola
Address (if different from player)
10355 Langdon Avenue
City
Mission Hills
State
California
Zip Code
91345
E-mail Address
Employer
Aerospace and Defence
Area Code
818
Business/Cellular Telephone
939-3866
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2   X Father      Mother      Guardian      Other

First Name
John
Middle Name
 
Last Name
Arriola
Address (if different from player)
10355 Langdon Avenue
City
Mission Hills
State
California
Zip Code
91345
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
939-4176
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature Adriana Arriola Date 07/03/2018

Electronic Signature Record   YUID: eRcy-2957162-AYSO1-109T/UxgR-2957163-AYSO1-109F
Current Date & time: 21-Nov-18 08:36:00 PST
IP address: 166.sub-174-211-18.myvzw.com (174.211.18.166)
Agreed to E-Sign Disclosures at: 03-Jul-18 13:40:36 PDT

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Ava 		Middle Name
A 		Last Name
Arriola 		AYSO ID #: 77452446

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Ava Arriola        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Adriana Arriola        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      80090496  

 
Region Number
8
Division
Clone of 10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Janie
Middle Name
 
Last Name
Cobian
Suffix
 
Area Code
818
Telephone
307-7439
Nickname
 
Street Address
9251 Rubio Ave
City
North Hills
State
California
Zip Code
91343
Mailing Address (if different from street address)
9251 Rubio Avenue
City
North Hills
State
CA
Zip Code
91343
Emergency Contact (other than parent)
Oscar Cobian
Area Code
818
Emergency Telephone
521-3861
Physician Name
Dr. Koshak
Area Code
818
Physician Telephone
368-8176
Gender
   Boy X Girl
Birthdate
11/22/2010
Age
7
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
Anthem Blue Cross  1191ZQ
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
Janie might need an inhaler depending on weather conditions.
Yrs of Experience
2
Height
 
Weight
40
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father   X Mother      Guardian      Other

First Name
Yazmin
Middle Name
 
Last Name
Cobian
Address (if different from player)
9251 Rubio Ave
City
North Hills
State
California
Zip Code
91343
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
307-7439
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2   X Father      Mother      Guardian      Other

First Name
Oscar
Middle Name
 
Last Name
Cobian
Address (if different from player)
9251 Rubio Ave
City
North Hills
State
California
Zip Code
91343
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
521-3861
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Player Signature JANIE COBIAN Date 12/20/2017

Electronic Signature Record   YUID: YVzS-1497309-AYSO1-107T/cL4W-1497310-AYSO1-107F
Current Date & time: 21-Nov-18 08:36:00 PST
IP address: 47.156.96.75
Agreed to E-Sign Disclosures at: 20-Dec-17 20:31:13 PST

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Janie 		Middle Name
  		Last Name
Cobian 		AYSO ID #: 80090496

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Janie Cobian        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  JANIE COBIAN        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      77139760  

 
Region Number
8
Division
10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Sapphire
Middle Name
S.
Last Name
Husany
Suffix
 
Area Code
818
Telephone
800-9911
Nickname
 
Street Address
7939 Jellico Ave
City
Northridge
State
California
Zip Code
91325
Mailing Address (if different from street address)
7939 Jellico Ave
City
Northridge
State
CA
Zip Code
91325
Emergency Contact (other than parent)
Guy Husany
Area Code
818
Emergency Telephone
800-9911
Physician Name
 
Area Code
 
Physician Telephone
 
Gender
   Boy X Girl
Birthdate
8/30/2010
Age
7
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
Kaiser
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
N/A
Yrs of Experience
3
Height
3.9
Weight
 
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1   X Father      Mother      Guardian      Other

First Name
Guy
Middle Name
 
Last Name
Husany
Address (if different from player)
7939 Jellico Ave
City
Northridge
State
California
Zip Code
91325
E-mail Address
Employer
Pinnacle Estate Properties
Area Code
818
Business/Cellular Telephone
800-9911
Area Code
818
Home Telephone
800-9911
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian      Other

First Name
 
Middle Name
 
Last Name
 
Address (if different from player)
 
City
 
State
 
Zip Code
 
E-mail Address
 
Employer
 
Area Code
 
Business/Cellular Telephone
 
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature guy husany Date 06/30/2018

Electronic Signature Record   YUID: lbvN-2882998-AYSO1-109T/PYAz-2882999-AYSO1-109F
Current Date & time: 21-Nov-18 08:36:00 PST
IP address: cpe-76-168-172-121.socal.res.rr.com (76.168.172.121)
Agreed to E-Sign Disclosures at: 30-Jun-18 11:46:05 PDT

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Sapphire 		Middle Name
S. 		Last Name
Husany 		AYSO ID #: 77139760

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Sapphire Husany        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  guy husany        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      200392660  

 
Region Number
8
Division
Clone of 10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Elisa
Middle Name
Rose
Last Name
Jauregui
Suffix
 
Area Code
 
Telephone
 
Nickname
Lee-C
Street Address
27736 Morning Glory Pl
City
Castaic
State
California
Zip Code
91384
Mailing Address (if different from street address)
27736 Morning Glory Pl.
City
CASTAIC
State
CA
Zip Code
91384
Emergency Contact (other than parent)
Carmen Jauregui
Area Code
818
Emergency Telephone
618-9025
Physician Name
Jennifer Moffet
Area Code
888
Physician Telephone
778-5000
Gender
   Boy X Girl
Birthdate
7/15/2010
Age
7
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
Kaiser Permanente  0019342341
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
 
Yrs of Experience
0
Height
4.3
Weight
100
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father   X Mother      Guardian      Other

First Name
Carmen
Middle Name
 
Last Name
Jauregui
Address (if different from player)
27736 Morning Glory Pl
City
Castaic
State
California
Zip Code
91384
E-mail Address
Employer
Pacoima Charter School
Area Code
818
Business/Cellular Telephone
618-9025
Area Code
661
Home Telephone
295-6759
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian      Other

First Name
Frank
Middle Name
 
Last Name
Jauregui
Address (if different from player)
27736 Morning Glory Pl
City
Castaic
State
California
Zip Code
91384
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
618-9028
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature Carmen Jauregui Date 01/29/2018

Electronic Signature Record   YUID: 2chq-2038691-AYSO1-107T/9Aal-2038692-AYSO1-107F
Current Date & time: 21-Nov-18 08:36:00 PST
IP address: 108-228-1-241.lightspeed.irvnca.sbcglobal.net (108.228.1.241)
Agreed to E-Sign Disclosures at: 29-Jan-18 21:07:26 PST

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Elisa 		Middle Name
Rose 		Last Name
Jauregui 		AYSO ID #: 200392660

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Elisa Jauregui        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Carmen Jauregui        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      205336949  

 
Region Number
8
Division
Clone of 10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Natalie
Middle Name
 
Last Name
Kobramasihi
Suffix
 
Area Code
818
Telephone
384-4036
Nickname
 
Street Address
7918 amestoy ave
City
Van nuys
State
California
Zip Code
91406
Mailing Address (if different from street address)
7918 amestoy ave
City
Van Nuys
State
CA
Zip Code
91406
Emergency Contact (other than parent)
Claudia Kobramasihi
Area Code
818
Emergency Telephone
384-4036
Physician Name
Dr kyoung soo yoo
Area Code
818
Physician Telephone
891-1616
Gender
   Boy X Girl
Birthdate
7/6/2009
Age
8
School Name
Holmes
Family E-mail address
Medical Insurance Carrier Policy #
Health net  R11745333
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
None
Yrs of Experience
1
Height
3.2
Weight
70
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father   X Mother      Guardian      Other

First Name
Claudia
Middle Name
 
Last Name
Kobramasihi
Address (if different from player)
7918 amestoy ave
City
Van nuys
State
California
Zip Code
91406
E-mail Address
Employer
Lausd
Area Code
818
Business/Cellular Telephone
384-4036
Area Code
818
Home Telephone
996-9954
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian      Other

First Name
 
Middle Name
 
Last Name
 
Address (if different from player)
 
City
 
State
 
Zip Code
 
E-mail Address
 
Employer
 
Area Code
 
Business/Cellular Telephone
 
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Player Signature Claudia Kobramasihi Date 02/22/2018

Electronic Signature Record   YUID: 04YY-241060-AYSO1-108T/P6Io-241061-AYSO1-108F
Current Date & time: 21-Nov-18 08:36:01 PST
IP address: 172.58.29.14
Agreed to E-Sign Disclosures at: 22-Feb-18 16:52:23 PST

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Natalie 		Middle Name
  		Last Name
Kobramasihi 		AYSO ID #: 205336949

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Natalie Kobramasihi        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Claudia Kobramasihi        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      77593358  

 
Region Number
8
Division
Clone of 10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Stacey
Middle Name
Michelle
Last Name
Nolasco
Suffix
 
Area Code
818
Telephone
335-4353
Nickname
 
Street Address
9307 Hayvenhurst Ave
City
North Hills
State
California
Zip Code
91343
Mailing Address (if different from street address)
9307 Hayvenhurst Avenue
City
North Hills
State
CA
Zip Code
91343
Emergency Contact (other than parent)
Marvin Nolasco
Area Code
818
Emergency Telephone
335-4353
Physician Name
Eisner Pediatric Family
Area Code
818
Physician Telephone
920-9947
Gender
   Boy X Girl
Birthdate
9/15/2010
Age
7
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
health net  91243101F
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
n/a
Yrs of Experience
0
Height
3.10
Weight
41
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1   X Father      Mother      Guardian      Other

First Name
Marvin
Middle Name
 
Last Name
Nolasco
Address (if different from player)
9307 Hayvenhurst Ave
City
North Hills
State
California
Zip Code
91343
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
335-4353
Area Code
818
Home Telephone
892-5836
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian      Other

First Name
 
Middle Name
 
Last Name
 
Address (if different from player)
 
City
 
State
 
Zip Code
 
E-mail Address
 
Employer
 
Area Code
 
Business/Cellular Telephone
 
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature Marvin Nolasco Date 12/28/2017

Electronic Signature Record   YUID: Saqq-1537894-AYSO1-107T/Ym55-1537895-AYSO1-107F
Current Date & time: 21-Nov-18 08:36:01 PST
IP address: 47.155.59.7
Agreed to E-Sign Disclosures at: 28-Dec-17 15:39:34 PST

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Stacey 		Middle Name
Michelle 		Last Name
Nolasco 		AYSO ID #: 77593358

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Stacey Nolasco        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Marvin Nolasco        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      78707545  

 
Region Number
8
Division
10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
SOPHIA
Middle Name
VALENTINA KAUR
Last Name
RUIZ
Suffix
 
Area Code
818
Telephone
224-0453
Nickname
 
Street Address
17728 tulsa st
City
Granada Hills
State
California
Zip Code
91344
Mailing Address (if different from street address)
17728 Tulsa st
City
Granada hills
State
CA
Zip Code
91344
Emergency Contact (other than parent)
Anita Ruiz
Area Code
818
Emergency Telephone
224-0453
Physician Name
Dr Fearherstone
Area Code
818
Physician Telephone
340-3570
Gender
   Boy X Girl
Birthdate
7/4/2009
Age
9
School Name
Tulsa Elementary
Family E-mail address
Medical Insurance Carrier Policy #
La care  98292506F
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
None
Yrs of Experience
3
Height
4.5
Weight
78
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father   X Mother      Guardian      Other

First Name
Anita
Middle Name
 
Last Name
Ruiz
Address (if different from player)
17728 tulsa st
City
Granada Hills
State
California
Zip Code
91344
E-mail Address
Employer
self
Area Code
818
Business/Cellular Telephone
224-0453
Area Code
818
Home Telephone
224-0453
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian      Other

First Name
 
Middle Name
 
Last Name
 
Address (if different from player)
 
City
 
State
 
Zip Code
 
E-mail Address
 
Employer
 
Area Code
 
Business/Cellular Telephone
 
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature Anita Ruiz Date 07/24/2018

Electronic Signature Record   YUID: 0w1N-3389304-AYSO1-109T/Y5ei-3389305-AYSO1-109F
Current Date & time: 21-Nov-18 08:36:01 PST
IP address: cpe-104-34-132-53.socal.res.rr.com (104.34.132.53)
Agreed to E-Sign Disclosures at: 24-Jul-18 20:42:58 PDT

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
SOPHIA 		Middle Name
VALENTINA KAUR 		Last Name
RUIZ 		AYSO ID #: 78707545

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 SOPHIA RUIZ        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Anita Ruiz        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date
 
AYSO ESign - Player Registration
AYSO small logo  American Youth Soccer Organization

www.ayso.org

  

Player Registration Form

Membership Year:   MY2018  
AYSO ID #:      204984019  

 
Region Number
8
Division
Clone of 10u Girls (8, 9)
Check if a VIP Player
  
Loc. Code
 

Player

First Name
Izmeralda
Middle Name
Rube
Last Name
Solis
Suffix
 
Area Code
818
Telephone
390-8074
Nickname
Izzy
Street Address
9338 Dorrington ave.
City
Arleta
State
California
Zip Code
91331
Mailing Address (if different from street address)
9338 Dorrington Ave.
City
Arleta
State
CA
Zip Code
91331
Emergency Contact (other than parent)
Juan Castaneda
Area Code
818
Emergency Telephone
310-2355
Physician Name
 
Area Code
 
Physician Telephone
 
Gender
   Boy X Girl
Birthdate
1/9/2009
Age
9
School Name
 
Family E-mail address
Medical Insurance Carrier Policy #
 
Siblings to play with:
 
Current Injuries or Minor Physical Limitations or other medical condition the coach should know about:
 
Yrs of Experience
0
Height
4.2
Weight
68
Region Specific Message:
 

If Player is a minor, provide Parent/Guardian #1      Father      Mother      Guardian   X Other

First Name
Juan
Middle Name
 
Last Name
Castaneda
Address (if different from player)
9338 Dorrington ave.
City
Arleta
State
California
Zip Code
91331
E-mail Address
Employer
 
Area Code
818
Business/Cellular Telephone
310-2355
Area Code
818
Home Telephone
893-5522
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

If Player is a minor, provide Parent/Guardian #2      Father      Mother      Guardian   X Other

First Name
 
Middle Name
 
Last Name
 
Address (if different from player)
 
City
 
State
 
Zip Code
 
E-mail Address
 
Employer
 
Area Code
 
Business/Cellular Telephone
 
Area Code
 
Home Telephone
 
AYSO is an all volunteer organization. I apply to:      Coach      Asst. Coach
   Referee      Team Parent      Other
If you have not already done so, please complete and submit a volunteer application. And thank you in advance for volunteering.

Authorization, Disclaimer, Assumption of Risk and Waiver and Consent Agreements

EMERGENCY AUTHORIZATION: I, hereby authorize each of the coaches, team parents, or other officials of AYSO to act as my agents in the capacity of activity supervisors and vehicle drivers, and I authorize each of them as well as the above-identified Emergency Contact to consent to medical, surgical or dental examination and/or treatment.

I HAVE READ THE EMERGENCY AUTHORIZATION AND ALL AGREEMENTS SET FORTH HEREIN, AND I FULLY UNDERSTAND THE TERMS OF EACH AND THAT I AND PLAYER HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I SIGN THIS FORM FOR MYSELF AND, IF PARENT, ON BEHALF OF PLAYER AND MEMBERS OF PLAYER???S FAMILY, AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT. I ALSO AGREE TO INFORM AYSO IN A TIMELY MANNER IF ANYTHING ON THIS FORM CHANGES.

{read more}

Parent/Guardian Signature Juan Castaneda Date 01/30/2018

Electronic Signature Record   YUID: oyX7-2057349-AYSO1-107T/fov3-2057350-AYSO1-107F
Current Date & time: 21-Nov-18 08:36:01 PST
IP address: cpe-172-250-164-1.socal.res.rr.com (172.250.164.1)
Agreed to E-Sign Disclosures at: 30-Jan-18 16:33:28 PST

DOB Verification Check Number Fee Charged Amount Paid
       

This document contains confidential and/or proprietary information and is the property of the American Youth Soccer Organization

  © 2016 American Youth Soccer Organization   Rev. 2016

 
  First Name
Izmeralda 		Middle Name
Rube 		Last Name
Solis 		AYSO ID #: 204984019

Disclaimer, Assumption of Risk and Waiver and Consent Agreement (???Waiver Agreement???)

DISCLAIMER, ASSUMPTION OF RISK AND WAIVER: I ACKNOWLEDGE THAT PARTICIPATION IN SOCCER NECESSARILY INVOLVES TRAVEL, PLAY IN ADVERSE FIELD CONDITIONS, CONTACT WITH CONSIDERABLE FORCE, AND RISK OF SEVERE, PERMANENT PHYSICAL INJURY INCLUDING BRUISES, SCRAPES, STRAINED, SPRAINED OR TORN MUSCLES, TENDONS OR LIGAMENTS, BROKEN BONES, DISLOCATION OF JOINTS, CONCUSSION, BRAIN DAMAGE, NERVE AND SPINAL CORD INJURY, PARALYSIS AND DEATH. I WILLINGLY AND VOLUNTARILY ASSUME ALL SUCH RISKS, BOTH KNOWN AND UNKNOWN, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES (THE TERM ???RELEASEES??? IS DEFINED BELOW.). I AGREE TO COMPLY WITH THE STATED AND CUSTOMARY TERMS AND CONDITIONS FOR PARTICIPATION OR CONTINUED PARTICIPATION AND, IF THE PARTICIPANT (???PLAYER???) OR I OBSERVE ANY CONCERN IN PLAYER'S READINESS FOR PARTICIPATION IN PRACTICES, GAMES OR OTHER ACTIVITIES (???EVENTS???), I WILL REMOVE PLAYER FROM PARTICIPATION AND IMMEDIATELY BRING SUCH CONCERN TO THE ATTENTION OF THE NEAREST OFFICIAL AND THE REGIONAL COMMISSIONER AS SOON AS POSSIBLE.

I HEREBY RELEASE, DISCHARGE AND AGREE TO HOLD HARMLESS, TO THE FULLEST EXTENT PERMITTED BY LAW, THE AMERICAN YOUTH SOCCER ORGANIZATION (???AYSO???), ITS PLAYERS, EMPLOYEES, VOLUNTEERS, OFFICIALS, SPONSORS AND OTHER REPRESENTATIVES AND ALL OWNERS, LESSORS, LESSEES OR OTHER PERSONS OR ENTITIES ALLOWING THE USE OF FACILITIES BY AYSO AND THE AGENTS, EMPLOYEES, OFFICERS AND DIRECTORS OF SAID PERSONS OR ENTITIES (???RELEASEES???) FROM ALL CLAIMS, DEMANDS, CAUSES OF ACTION, COSTS, EXPENSES AND COMPENSATION ARISING OUT OF OR IN ANY WAY RELATED TO A LOSS, INJURY OR OTHER DAMAGE TO PLAYER OR TO MEMBERS OF MY FAMILY OR MY HOUSEHOLD OR INDIVIDUALS I INVITE OR FOR WHOM I AM OTHERWISE RESPONSIBLE, OR TO THEIR PROPERTY, WHILE PARTICIPATING IN OR PRESENT AT ANY OF THE EVENTS, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. I ACKNOWLEDGE THAT AYSO IS PRIMARILY ADMINISTERED BY VOLUNTEERS RATHER THAN PAID PROFESSIONALS.

I ACKNOWLEDGE AND AGREE THAT THIS WAIVER AGREEMENT IS INTENDED TO BE AS BROAD AND INCLUSIVE AS PERMITTED BY THE LAWS OF THE STATE IN WHICH WE LIVE AND AGREE THAT IF ANY PORTION OF THIS WAIVER AGREEMENT IS DEEMED TO BE INVALID, THE REMAINDER WILL CONTINUE IN FULL LEGAL FORCE AND EFFECT.

ACKNOWLEDGEMENT AND CONSENT:
I understand the terms of the Soccer Accident Insurance Plan are set forth in a pamphlet available on-line at http://www.ayso.org, as may be amended from time to time, and either I have read and understand the terms or I will do so before Player participates in any Events.

I have received the AYSO/CDC Parent/Athlete Concussion Information Sheet (also available online at http://www.ayso.org) which contains information related to a) signs and symptoms of a concussion; b) danger signs associated with a concussion; c) why athletes should report symptoms related to a concussion; and d) what should be done if a concussion is suspected. I agree to review the Concussion Information Sheet (or review with Player) and return a signed copy to Player???s coach on the first day of practice.

For internal and external use, AYSO may obtain, compile and use contact information, soccer photographs and audio visual recordings of Player consistent with the AYSO Privacy Policy set forth at http://www.ayso.org, as may be amended from time to time. I consent to such uses and hereby waive all rights to approval and compensation.

On behalf of myself, or Player (if Parent), and all members of my family or child???s family, I hereby agree to abide by the AYSO Bylaws, rules, regulations, policies and philosophies as available at http://www.ayso.org, as may be amended from time to time, and all decisions and directions of the Regional Board, Area and Section staff, and the National Board of Directors, and agree that Player or any member of Player???s family may be removed from the program at any time with or without cause. I represent that Player has not been convicted of any crime nor does Player have any known condition that might pose undue risk to other participants.

(Please signify your agreement with the foregoing by signing in the space indicated on the top of this form.)

 

Parent/Athlete Concussion
Information Sheet

A concussion is a type of traumatic brain injury that changes the way the brain normally works. A concussion is caused by bump, blow or jolt to the head or body that causes the head and brain to move rapidly back and forth. Even a "ding," "getting your bell rung," or what seems to be a mild bump or blow to the head can be serious.

WHAT ARE THE SIGNS AND SYMPTOMS
OF CONCUSSION?

This information sheet was produced in cooperation with the Center for Disease Control (CDC).

DID YOU KNOW?

Most concussions occur without loss of consciousness.
Athletes who have, at any point in their lives, had a concussion have an increased risk for another concussion.
Young children and teens are more likely to get a concussion and take longer to recover than adults.

Signs and symptoms of concussion can show up right after the injury or may not appear or be noticed until days or weeks after the injury.

If an athlete reports one or more symptoms of concussion listed

below after a bump, blow, or jolt to the head or body, s/he should be kept out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.
SIGNS OBSERVED BY COACHING STAFF SYMPTOMS REPORTED BY ATHLETES

Appears dazed or stunned
Is confused about assignment or position
Forgets an instruction
Is unsure of game, score, or opponent
Moves clumsily
Answers questions slowly
Loses consciousness (even briefly)
Shows mood, behavior, or personality changes
Can't recall events prior to hit or fall
Can't recall events after hit or fall

Headache or "pressure" in head
Nausea or vomiting
Balance problems or dizziness
Double or blurry vision
Sensitivity to light
Sensitivity to noise
Feeling sluggish, hazy, foggy, or groggy
Concentration or memory problems
Confusion
Just not "feeling right" or "feeling down"

CONCUSSION DANGER SIGNS

In rare cases, a dangerous blood clot may form on the brain in a person with a concussion and crowd the brain against the skull. An athlete should receive immediate medical attention if after a bump, blow or jolt to the head or body s/he exhibits any of the following danger signs:

One pupil larger than the other
Is drowsy or cannot be awakened
A headache that not only does not diminish, but gets worse
Weakness, numbness, or decreased coordination
Repeated vomiting or nausea
Slurred speech
Convulsion or seizures
Cannot recognize people or places
Becomes increasingly confused, restless, or agitated
Has unusual behavior
Loses consciousness (even a brief loss of consciousness should be taken seriously)

WHY SHOULD AN ATHLETE REPORT THEIR SYMPTOMS?

If an athlete has a concussion, his/her brain needs time to heal. While an athlete's brain is still healing, s/he is much more likely to have another concussion. Repeat concussions can increase the time it takes to recover. In rare cases, repeat concussions in young athletes can result in brain swelling or permanent damage to their brain. They can even be fatal.

Remember

Concussions affect people differently. While most athletes with a concussion recover quickly and fully, some will have symptoms that last for days, or even weeks. A more serious concussion can last for months or longer.

WHAT SHOULD YOU DO IF YOU THINK
YOUR ATHLETE HAS A CONCUSSION?

If you suspect that an athlete has a concussion, remove the athlete from play and seek medical attention. Do not try to judge the severity of the injury yourself. Keep the athlete out of play the day of the injury and until a health care professional, experienced in evaluating for concussion, says s/he is symptom-free and it's OK to return to play.

Rest is key to helping an athlete recover from a concussion. Exercising or activities that involve a lot of concentration, such as studying, working on the computer, or playing video games, may cause concussion symptoms to reappear or get worse. After a concussion, returning to sports and school is a gradual process that should be carefully managed and monitored by a health care professional.

It's better to miss one game than the whole season.
For more information on concussions,
Visit : www.cdc.gov/Concussion
 Izmeralda Solis        
 Student-Athlete Name Printed    Student-Athlete Signature    Date
  Juan Castaneda        
 Parent or Legal Guardian Printed    Parent or Legal Guardian Signature    Date