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REGISTRATION FEE:
$30.00/CHILD DEADLINE:
FEBRUARY 15, 2012 $40.00
PER CHILD AFTER 2/15/12
2012
SPRING
2012 REGISTRATION
_____________________________________________________________________________
GRADE: PreK
K
1
2
3
4
5
6
7
8
(PLEASE PRINT)
CHILDS NAME:
_______________________ SEX:
M___ F___ PHONE:
______________
ADDRESS:
___________________________
CITY: ___________________ ZIP:
_______
PARENTS NAME:
_____________________ CELL:
______________ TEXT: YES OR NO
PARENTS NAME:
_____________________ CELL:
______________ TEXT: YES OR NO
BIRTHDATE:
_________________________
EMAIL: _____________________________
(Must be four (4) years old by September 1, 2011)
Has your child played soccer before? ____ NO ____ YES (IF YES) WHEN: ___________________
Selected to a prior all star team? ____ NO ____ YES (IF YES) WHEN: ___________________
Is your child a carded select player? ____ NO ____ YES
Interested in becoming a Referee? ____ NO ____ YES
Interested in coaching? ____ NO ____ YES _____ ASSIST
COACH: _______________________________ ASSISTANT: _______________________________
I/WE, parents of the above
named youth, hereby give my/our approval for above named youth to participate in
all league activities during the current season.
I/WE assume all risks and hazards incidental to such participation, and
I/WE do hereby waive, release, absolve, indemnify and agree to hold harmless
local league and any of its affiliates (sponsors, national franchises,
supervisors) for any claims arising out of an injury to the above named youth.
_________________________________ ____________________________________ ______________
Parent/Guardian’s Name –
PLEASE
PRINT
SIGNATURE
DATE
Registration
Deadline is February 15, 2012
Registrations
received after this date will be charged a $10.00 late charge.
MAIL
COMPLETED FORM & FEE PAYABLE TO: