NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association) 20~-20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #. _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

=L_u_k~e~

~A~.~~B_is~h_o~p

~T_(_la_n~g_le_F_u_t_bO_I_C_I_U_b
Full Association Name

tf~~Jersey # Sex

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

October 7, 1998
Birth Date

DAcademy

DChallenge
Cary

[{] Level

Classic

DRecreation

D Male 0 Female
NC 27519
919.389.9375

106 Seymour Creek Drive

7A7dd~re-s-so~f~P~la-~-r---------------C~i~~~----------~St~at~e---------Z=ip

Sharon Bishop
ParentiLegal Guardian Full Name

919_363.5895
Home Phone Work Phone

Cilil Phone
919.943.3195

Mark Bishop
Additional Person to Contact in an Emergency

919_363.5895
Address

919.474.6603
Home Phone

Cell Phone

November 13, 2009

Date of Last Tetanus Shot

None
Medications now being taken

Polio vaccine
Player is Allergic to these Medications and Substances

None
List any Unusual Health Information

sharib46@gmail.com
Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Wake , state of NC , the parentsleqal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibili~ of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registran~ release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and aliliabili~, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone 01the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an anempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physidan, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Information: Name of Insurance Company:

Blue Cross Blue Shield of NC

ID Number:

YPPW14532663

"No Electronic Signature Permitted

Confirmation Number:

June 8, 2013
Date

Original (Team)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association) 20~20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NCYSA Policy /#.

Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

Brendan

Boss

Triangle Futbol Club

Full Association Name

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

o
12] Male
NC
State

Jersey #

11/6/1998
Birth Dale

DAcademy

DChallenge IZl Classic

Level

DRecreation

0 Female
Sex

2312 Becketts Ridge Dr.

Address of Player

Hillsborough
City

27278
Zip

Robert David Boss Jr

ParentILegal Guardian Full Name

919-241-4431
Home Phone

401-742-7450
Work Phone Cell Phone

Holly Boss
Additional Person to Contact in an Emergency

2312 Becketts Ridge Dr.

Address

919-932-2884
Home Phone Cell Phone

12/9/2008
Date of Last Tetanus Shot

Albuteral Inhaler for asthma when needed

Medications now being taken

Player is Allergic to these Medications and Substances

david@bosspc.com
List any Unusual Health Information Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Orange , state of NC , the parentsllegal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow thai child 10 practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NeYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registranrs participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, joinlly and severally, as parents and legal guardians of the Reqisfrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees thaI there is not lime to make such an attempt, 10 consent to any x-ray examination, anesthetic. medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Information: Name of Insurance Company:

BlueCrass BlueShield

10 Number:

YPPW15380520

"No Electronic Signature Permitted

Confirmation Number:

6/10/2013
Date

Original (Team)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association) 20~20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #. _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

Anthony

Boswell

Triangle Futbol Club

Full Association Name Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

12/19/1998
Birth Date

DAcademy

D Challenge
Cary
City

[{] Level

Classic

Recreation

[{]

Male

0 Female
Sex

308 Preston Oaks Lane

Address of Player

NC
State

27513
Zip
919-6224540

Tammy Boswell
ParentiLegal Guardian Full Name

919-319-7430
Home Phone

919-863-8062
Work Phone

Cell Phone
919961-6143

Keith Boswell
Additional Person to Contact in an Emergency

919-319-7430
Address

919-961-6143
Home Phone

Cell Phone

12/29/2003
Date of Last Tetanus Shot

N/A
Medications now being taken

None known
Player is Allergic to these Medications and Substances

None
List any Unusual Health Information

Tboswell@nc.rr.com
Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Wake ,state of N C , the parentsllegal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby joinHy and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, induding the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registranfs participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, joinHy and severally, as parents and legal guardians of the Registran~ release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and aI/liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or partidpating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Information: Name of Insurance Company:

UnitedHealthcare
Plan #911-87726-04,Member #962507995,Group #743276

10 Number:

"No Electronic SignabJre Permitted

Confirmation Number:

6/10/13
Date

Original (Team)

Copy (Association)

..1_~
NeYSA
PO Box 18229 Greensboro, NC 27419

N_O_R_T_H_C_A_R_O_L_IN_A

M_ed_iC_a_I_CO_n_s_e_nt_'----,W,---a_iv_er-,-o----,f_L,---ia_b_ili---!ty_a_n_d_R_e_le_as_e
(To be given to your local association)

20~20~
NeYSA Policy #

336.856.7529

Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

William

M. L.

Dugger

Triangle Futbol Club

Full Association Name

10
Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

October 9, 1998
BirtlJDate

OAcademy

0Challenge
Apex
City

[{] Level

Classic

DRecreation

ILlMale
NC
State

0 Female
Sex

710 Martha's Chapel Road

Address of Player

27523
Zip

Melea Lyn Lemon

Parent/Legal Guardian Full Name

919-362-8444
Home Phone

919-805-4308
Work Phone

n/a
Cell Phone

Larry Edward Dugger

Additional Person to Contact in an Emergency

313 Glen Abbey Dr. Cary

Address

919-795-7038
Home Phone Cell Phone

10/09
Date of Last Tetanus Shot

n/a
Medications now being taken

Amoxicillian
Player is Allergic to these Medications and Substances

n/a
List any Unusual Health Information

melealemon@gmail.com
Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Wake . state of NC , the parentsllegal guardian of the above Registran~ a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I(we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the Programs'), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registranfs participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Infonnation: Name of insurance Company:

BeBS
YPPW14507421 064795

'i~k
"ParentILegal Guardian Signature "No Electronic Signature Pennitted

IDNumber:

Confirmation Number:

6/17/13
Date

Original (Team)

Copy (Association)

- I
NeYSA
PO Box 18229 Greensboro. NC 27419 336.856.7529

--------------------------------------------------------------------------~----------------------------~ (To be given to your local association) 20~.20~

NeYSA Policy # _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player. this policy is primary after the deductible.

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

Archie

Filliter

~'A,..JC,t....~
DAcademy

=PI:-ay-e-r =Fi:-rs:-t NC":"a-m-e----M:-:-:'"ln:-iu:-' a:-I---,L:-a-st-:N-:-a-m-e------------(AS APPEARS ON BIRTH CERTIFICATE)

Full Association Name

t-U.'T&OL

(:.~S

11
Jersey # Male

12/22/1998
Birth Date

DChallenge
Apex
City

~SiC Level

D Recreation
NC
State

0 Female
Sex

1008 Tamora Court

Address of Player

27501
Zip

Kelly-May L. O'Neill
Parent/Legal Guardian Full Name

919-260-0781
Home Phone Work Phone Cell Phone

John C. O'Neill
Additional Person to Contact in an Emergency

1008 Tamora Ct.

Address

919-723-8694
Home Phone Cell Phone

Date of Last Tetanus Shot

Medications now being taken

Player is Allergic to these Medications and Substances

t-4SN
List any Unusual Health Information

-CoM

Fl rent Email For Soccer Information

I (we). the undersigned. residing in the county of state 01 ,the parents/legal guardian olthe above Registrant, a minor, who resides with us. do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of phySical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any daim by or on behalf of the Registrant as a result of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally. as parents and legal guardians of the Registranl release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the 'above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the deSignated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain ccnsent or if sound medical practice decrees that there is not time to make such an attempt, to ccnsent to any x-ray examination, anesthetic, medical or surgical procedure. treatment, and/or hospital care. to be rendered to the Registrant under the general or special supervision of and/or on the advise 01any physician. surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Wake

NC

Insurance Information: Name of Insurance Company:

scss
YPPW14032121
"No Electronic Signature Permitted

10 Number:

Confirmation Number:

Ol.D-/5-i8
Date

Original (Team)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association)

20~20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #. _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

Kevin

Germain

Triangle Futbol Club

Full Association Name

16
Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

09/09/1998
Birth Date

DAcademy

0 Challenge 0 Classic
Level

DRecreation

o
NC
State

Male

0 Female
Sex

103 Reinhold Lane

Address of Player

Cary
City

27513
Zip
919--454-2628

Shelley Germain
Parent/Legal Guardian Full Name

919-466-7673
Home Phone

919-454-2628
Work Phone

Cell Phone

Gregory Germain
Additional Person to Contact in an Emergency

same
Address

919-466-7673
Home Phone Cell Phone

6/2008
Date of Last Tetanus Shot

none
Medications now being taken

none
Player is Allergic to these Medications and Substances

none
List any Unusual Health Information

shanghaishelley8@gmail.com Parent Email For Soccer Information

I (we), the undersigned, residing in the county of state of ,the parents/legal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United Slates Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnity the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained While present or participating in the Programs or traveling to or from events in the Programs or while on tnps sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any Hay examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Wake

NC

Insurance Information: Name of Insurance Company:

United Healthcare 900113418 877-842-3210

Original (Team)

IDNumber:

"No Electronic Signature Permitted

Confirmation Number:

6/8/2013
Date

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association)

20~-20J!L
NeYSA
POBox 18229 Greensboro, NC 27419 336.856.7529 NeYSA Policy #' _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible,

\\ ;lee

~rst Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

t,.

"',sec
OAcademy

'1Cfarlate
Full Associati&liame

FiJh()/~
DRecreation ~Male

Jersey #

B.-~tO-qB

DChallenge

Classic

FemaJe

~~~~~~----------------------------~~~~~~~.~ List any Unusual Health Information

I (we), the undersigned, residing in the county of state of the parentsnegal guardian of the above RegistranL a minor, who resides with us, do hereby declare our intent to allow that child topiactice, train, play and participate in all soccer-rclated activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NeYSA accepting the Registrant for their soccer programs and activities (the' Programs'), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NeYSA, their affiliated organizations and sponsors, their employees and assodated personnel, induding the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registranfs participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Reqistrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an anempt, to consent to any Hay examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

LOa~

tilt. '

Insurance Information: Name of Insurance Company: **Parentf[egal Guardian Signature

ID Number:

"No Electronic Signature Pennitted

Confirmation Number: Date

Original (Team)

Copy (Association)

[
NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to lour local association) 20\_'~_-20 \ ~
NeYSA Poucy # _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

Jersey #

[1

Academy

I 1 Challenge

!XClassic

1 Recreation

[)cJ Male

[1

Female

~~c~z~;t;
Pt1""''''' """"'"
~C'cx:r--.
. (C)
~

FWIN,~

H~, PM",
Address

~\~)6 _PI,."

9~1~~~~
Co" ~
Cell Phone

Additional Person to Contact in an Emergency

1 DLo~0
C'X--X

~
\~

O~:'i)"r:-

Q'9J ~ q 7S?C)'-o~
Home Phone

;l.\)\~
[ast Tetanus Shot

Medications now being taken

0.Q\'s;

0>
~~~~~~-&~~~~~~~~~~~:~.~

~PI~ay~e~r_is~A~lIe~rg_i~c~ro_~~e~re~M_~_ica~tion~s~a_nd~S~u~~~t~~~ce~s~~

I (we), the undersqned, residing in the county of ~~ Ii? state of the parents/legal guardian of the above Registran~ a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United State:; Youth Socoer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, ~s affiliated organizations and sponsors. Recognizing the po~sibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accep~ng the Registrant for their soccer programs and activities (the" Programs"), we hereby jOintly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant 35 a result of the Registranrs participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and aUliabilily, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in ~e Programs or while on trips sponsored by or in conjunction \\1th the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any Hay examination, ~eslhetic, medical or surgical proeeoure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on ~e advise of any physician, surgeon or dentist duly licensed to practice. The undersiqned have read and fully understand and agree to the foregoing.

De

Insurance Information: Name of Insurance Company:

IDNumber:

C~\\,--\1;

\'-\~'l~~

~No Electronic Signature Permitted

Confirmation Number:

\ ~\e'-.Q~ "J.:2,CPl ~'-\

Date I

Original (Team)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiv~r of Liability and Release

(To be given to your local association)

20~20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #

Excess policy to any valid and collectible Insurance. If there is nq primary insurance on insurance on a player,lthis policy is primary after the dedJctible.

Jose

Maciel Madera

Triangle Futbol Club

Full Association Name

Ie
Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

July 1, 1999
Birth Date

OAcademy

DChallenge 0 Classic
Level

DRecreatlon

o
NC
State

Male

0 Female
Sex

1204 Croydon Glen ct.

Address of Player

Cary
City

27519
Zip
9197613016

Maribel Madera Garcia

ParentlLegal Guardian Full Name

9197613016
Home Phone Work Phone

Cell Phone
7043023967

Jose Maciel Enriquez

Additional Person to Contact in an Emergency

1204 Croydon Glen ct.

Address Home Phone

Cell Phone

7/21/2010
Date of Last Tetanus Shot

None
Medications now being taken

None
Player is Allergic to these Medications and Substances

None
List any Unusual Health Information

maribel_madera@yahoo.com Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Wake County , state of NC , the parenlS/legal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with tre above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a resut of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal imunes sustained while present or participating in the Programs or traveling to or from events in Programs or while on trips sponsored by or in conjunction with the Programs.

r
I

In addition, I (we) do hereby authorize anyone of the desqnated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical br surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dertist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Information: Name of Insurance Company:

Blue Cross Blue shield

"Parentl.eqal Guardian Signature

ID Number

DZVAN2794596 1-800-875-6139

"No Electronic Signature Permitted

Confirmation Number:

6/10/13
Date

Original (T earn)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association) 20li20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy # _ Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE) DAcademy Birth Date

D Challenge
City

~ Level

Classic

DRecreation

~Male

0 Female
Sex

17(0
Address of Player

~~(~;p~n~D~a~W~h~S~t~0~<T~p~e~y ~/V~~~' __ ~ ~~=-)~~_'~~_~ __

State Zip

11qy:k
,zOO
Date of Last Tetanus Shot

ParenULegal Guardian Full Name

p.

MqV''f1Vl /l1mt'f:in

j/j-r2b 7-jb
Home Phone

(0

2/9-??3{-s7t:<
Work Phone Home Phone

/:::.Vvn. J....

f710

Chav,(,pn

/JtJWnft.iJ

2ll-6:-6118 Cell Phone '17-22-261'0 111"'62(-6((9

Cell Phone

Additional PTrson to Contact In an Emergency

S;
Medication

Address

I (we), the undersigned, residing in the county of q; state of the parentsfeqal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the' Programs'), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registranfs participation in the Programs andlor being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, andlor hospital care, to be rendered to the Registrant under the general or special supervision of andlor on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

W /C.-~

k~,'1\vY\~ i-ifl) lJ 1 Ooyctnq; J, CO V\':t , Pare.nt Email For Socce/l~formation :...LJ /9-qvvtq; I V LA-Si1 ce JI1I~Ii' vc:; vn ec\"- f7 V') !/ c.o~

dc,

Insurance Information: Name of Insurance Company:

&c&S Sjqte /kq/~

f!t~h

~~

"ParenULegal Guardian Signature

10 Number:

Y PYtv/2407LjS;-o
'300 -

"No Electronic Signature Permitted

Confirmation Number:

67:2- "]'g Cj '/

------=-0_- r ?- I~
Date

3'f'" :<'flb S8&-R Original (Team)

Copy (Association)

~7.---------------------------------------------------------------------------------.
1

N_O_RT_H_C_A_RO_L1_N_A...,..,..M_e_d_ic_al_C_o_n_se_n_t_' W_ai_v_er-:-o_f---,.L_ia_bi_li~ty_a_n_d_R_e_le_as_e
(To be given to your local association) 20_13_20~

-----,
_

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #

Excess policy to any valid and collectible insurance. If there is no primary insurance on insurance on a player, this policy is primary after the deductible.

William

McLaughlin

Triangle Futbol Club

Full Association Name Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

2/28/1999
Birth Date

DAcademy

DChallenge
Cary
City

[{] Level

Classic

Recreation

Male

0 Female
Se~
27513
Zip
919-413-0336

200 Legault Drive

Address of Player

NC
State

Bill & Mary McLaughlin

Parent/Legal Guardian Full Name

919-388-1175
Home Phone

NC
Work Phone

Cell Phone

Maggie McLaughlin
Additional Person to Contact in an Emergency

200 Legault Drive

Address Home Phone Cell Phone

2011
Date of Last Tetanus Shot

none
Medications now being taken

none
Player is Allergic to these Medications and Substances

none
List any Unusual Health Information

marynappi 127@gmail.com
Parent Email For Soccer Information

I (we), the undersigned, residing in the county of Wa ke state of NC the parentsAegal guardian of the above Registrant, a minor, who resides with us, do hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the" Programs"), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized by the Programs, against any claim by or on behalf of the Registrant as a result of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, joinUy and severally, as parents and legal guardians of the Registrant release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the designated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby authorize anyone of the designated adults of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, and/or hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing.

Insurance Information: Name of Insurance Company:

Medcost

10 Number:

02160448C 8253 Original (Team)

"No Electronic Signature Permitted

Confirmation Number:

bll/b
Date

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and ReJ.se

(To be given to your local association) 20 Jl-20J!:iNeYSA
PO Box 1&229
Greensboro. NC2741~ NeYSA Policyi._+- __ Eic.ress policy to any valld collectible insurance.lflhere is no pr TYinsurance 011 insumnre on a P~)'ef,thl polley is lrimary after the ded!d,e.

336.856.7529

:M
J Academy

I J ChaUenge

~IassiC

1 Recreatim

1Female

Level
Address of Player Zip

-55J--9 70
Name HomePhane

fI

&

-7&05
Cell Phone CelfPhale

TteDf- M oDreheati
Additional Pe!soo to Cootad in an Emergency

ParentiLegal G rdianFul

~UmR. as gb~ve)
. Mdress 7

9/11-'ill-Co 7/3

DmeYL~/S[~O

I1IQ
Medicafroit no'll beilg taken

Pla}l'f

isAf[;:g;c tolhese

Medca:fioos and &!ootanIES

~~~~~~
List any Unusual slth lnrorrnaUoo

~~~~~~~~~~~;(Guflt

I (we),fue undersigne:t feS"dhg in the county of state of the parent;;llegalguard.i3n the above Registrant. a mina, wi\Qr1lSi:!es wilhus. do hereby dedare CAlf infeottoallcm lha! dJ.ildlo practice, train, play and participate in all soorer-related adilrities with the above mentioned soccerteam affiliated with f.heNorth C!lI'<lIlnaYQUth Sro;er Association andlheUniledSfatesYooth Soocer AssoCiatlon. I {we} agree thaI' we and lhe Regls!rant wit allde by the ruJes of l!le USYS, lis affiliated organlz;alions and sponsors. RectJgnizing the possibility of physical injury associ:lted with s.0CQeI"andin consideration forlhe USYS lInd NeYSA aooeptfng the Registrant for their soccer program!> andadtvilies (the' Programsj, we hereby JoinHyand severally release, di5charyeandtor dhe!Wise lndermlfYthe USYS, NeYSA, lheir"3ffiliated organrzalions and sponsors,therempfoyees and aseociated personnel, Dang the ONnersofflelds and facilities utJized by Ibe Programs, against any claim by or Of! behali ofthe Regl5trant as a result oflhe Registrant's participatioo in the Progmms and'or being lransportedlo orfrom the same, which transportation we- hereby authorize,

tl acneft

/ilL.

liwe) further, jehU,. and severally, as parents and legal guardians of lIIe Registrant, release, dilmarge, and agree to h<lld harmless andiJ'ldemnify the above-named mdvilUalsorany ofthedesignmedooadlesoflhe aboveTeamfrorn any and artliabilty, daims or demands arising from th.eRegistrant partlcPatingin the Prq;jram5wih the above Team specifically 10 indude any gnd all claims for personal mjulies Slslained while pooent or parijdpating in the Pr'Vamsor traveling roor from Wellts m the Progarnsorwllile Of! trips sponsored by or in coojunctioo wi!h the Programs,
In additioo, I {we-} do hereby authorize gny one of the designated adults of the Team, if after a reasonable attempt has been rnadeto 'food! a parent or guardian to attain coosent or if sound medicalprad:rre decreeslhm!here is no! time to make SId! an aft . to oonsent 10any x-ray exarnlnafion, anesthetic, medl:al or SlJJ'9icalJYOCedw'e, \reatmell~ andlor.hospital.care, lobe renderedtothe Registrant under the general or speOO.lsupervision of and/or 011the 00'..me of any p-tysidan, surgeoo ordentis! dulylicensedlo pradice. Theulldemigrled .have lood 8.'1<1 flllly Ilnderstarn:! aoo agree to lhMbregoir.g.

Ill.SUl'anCEIlnformatial

Name ci insurnnre Compmy:

~~~

"P

. . egal Guardian Signatu re

ID Number:

"No Beclrooie Signature Permil!ed

Conlfrrnation Number:

7oq33S
Original (T earn)

(0-/0-(7
Date

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be givento your locaLapsociation)

20Q.20~

NeYSA
PO Box 18229 Greensboro, NC 27419 336.856.7529

NeYSA Policy #. _ Excess policy to any valid and collectible insurance. If Ihere is no primary insurance on insurance on a player, Ihis policy is primary after Ihe deductible.

Connor

Munz

Triangle Futbol Club

Full Association Name

9
Jersey #

Player First Name M Initial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

9/18/1998
Birlh Date

DAcademy

DChallenge 0 Classic
Level

DRecreation

[{]

Male

0 Female
Sex

108 Barnes Spring Court

Address of Player

Cary
City

NC
State

27519
Zip
9196563346

Mary Beth Munz

Parent/Legal Guardian Full Name

9193039635
Home Phone

9196563346
Wor1<Phone

Cell Phone
9194488126

Rob Munz
Additional Person to Contact in an Emergency

Same
Address

9193039635
Home Phone

Cell Phone

9/2010
Date of Last Tetanus Shot

None
Medications now being taken

None
Player is Allergic to Ihese Medications and Substances

mbmunz@nc.rr.com
List any Unusual HeaHh Information Parent Email For Soccer Information

I (we), Ihe undersigned, residing in Ihe county of Wake ,state of NC , Ihe parentsllegalguardian of Ihe above Registrant, a minor, who resides with us, do hereby declare our intent to allow Ihat child to practice, train, play and participate in all soccer-related activities wilh Ihe above mentioned soccer team affiliated wilh Ihe Norlh Carolina Youlh Soccer Association and Ihe United States Youlh Soccer Association. I (we) agree Ihat we and Ihe Registrant will abide by Ihe rules of Ihe USYS, its affiliated organizations and sponsors. Recognizing Ihe possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for Iheir soccer programs and activities (lhe Programs;, we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, Iheir affiliated organizations and sponsors, Iheir employees and associated personnel, including Ihe owners of fields and facilities utilized by Ihe Programs, against any daim by or on behalf of Ihe Registrant as a result of Ihe Registranrs participation in Ihe Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) furlher, jointly and severally, as parents and legal guardians of the Registrant release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the desqnated coaches of the above Team from any and aliliabifity, daims or demands arising from Ihe Registrant participating in Ihe Programs wilh Ihe above Team specifically to indude any and all daims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on bips sponsored by or in conjunction with the Programs. In addition, I (we) do hereby aulhorize anyone of Ihe designated adults of Ihe Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain consent or if sound medical practice decrees Ihat Ihere is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical procedure, treatmeni and/or hospital care, to be rendered to Ihe Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to Ihe foregoing.

Insurance Information: Name of Insurance Company:

BCBS OF NC

10 Number:

""No Electronic Signature Permitted

Confirmation Number.

6/14/2013
Date

Original (Team)

Copy (Association)

NORTH CAROLINA Medical Consent I Waiver of Liability and Release

(To be given to your local association)

__

20~-20~

NeYSA
PO Box 18229 Greensboro, NC 27419

336.856.7529

"flttbD I primary after the deductitille.

M Zlotnik Triangle FC
Full Association Name

NeYSA Polley # Excess policy to any va-lid-s"-'nd-cc-IIe-ctible insurance. If there is no Pfimary insurance on insurance on a player, this policy is .

Mason

Club
DRecreation ~ale

I
:

II
Jersey #

Player First Name M In~ial Last Name (AS APPEARS ON BIRTH CERTIFICATE)

11/13/1998
Birth Date

DAcademy

D Challenge 0 Classic
Level

P Female
Sex

505 S. Dixon
Address of Player

Cary
cny

NC
State
I

2'7511
Zip'
9193893384

Stacy Zlotnik
ParenULegal Guardian Full Name

na
Home Phone

na
Work Phone

Cell Phone
9192198394

Marian Bendixsen
Additional Person to Contact in an Emergency

111 Breakers PI Cary

Address

9194639357
Home Phone

Cell Phone

na
Date of Last Tetanus Shot

na
Medications now being taken

na
Player is Allergic to these Medications and Substances

na
List any Unusual HeaHh Information

stacy.zlotnik@gmail.com
Parent Email For Soccer Information

I (we), the undersigned, residing in the ccunty of Wake , state of NC , theparentsllegal guardian of the above Registrant, a minor, who resides with us, 00 hereby declare our intent to allow that child to practice, train, play and participate in all soccer-related activities with the above mentioned soccer team affiliated with the North Carolina Youth Soccer Association and the United States Youth Soccer Association. I (we) agree that we and the Registrant will abide by the rules of the USYS, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYS and NCYSA accepting the Registrant for their soccer programs and activities (the' Programs'), we hereby jointly and severally release, discharge and/or otherwise indemnify the USYS, NCYSA, their afliliated organizations and sponsors, their employees and associated personnel, induding the owners of fields and facimies utilized by the Programs, against any claim by or on behalf of the Registrant as a resuH of the Registrant's participation in the Programs and/or being transported to or from the same, which transportation we hereby authorize. I (we) further, jointly and severally, as parents and legal guardians of the Registrant, release, discharge, and agree to hold harmless and indemnify the above-named individuals or any of the deSignated coaches of the above Team from any and all liability, claims or demands arising from the Registrant participating in the Programs with the above Team specifically to include any and all claims for personal injuries sustained while present or participating in the Programs or traveling to or from events in the Programs or while on trips sponsored by or in ccnjunction with the Programs. In addition, I (we) 00 hereby authorize anyone of the designated adutts of the Team, if after a reasonable attempt has been made to reach a parent or guardian to obtain ccnsent or if sound medical practice decrees that there is not time to make such an attempt, to ccnsent to any x-ray examination, anesthetic, medical or surgical procedure, treatment, anciior hospital care, to be rendered to the Registrant under the general or special supervision of and/or on the advise of any physician, surgeon or dentist duly licensed to practice. The undersigned have read and fully understand and agree to the foregoing,

Insurance Information: Name of Insurance Company:

BC/BS

10 Number:

ypyw12573045

group nO.S27089

"No Electronic Signature Permitted

Confirmation Number:

010-J5-/8
Date

Original (Team)

Copy (Association)