date of birth AWS
WINSTON-SALEM OPTIMIST SOCCER 3051-B Trenwest Drive, Winston-Salem, NC 27103 336-774-6773 WSOptimist.com
Registration Deadline: August 15, 2016 Late fee of $20 per player after 8/15/16 PLEASE PRINT. FORM MUST BE COMPLETED IN FULL TO GUARANTEE REGISTRATION.
PLAYER INFORMATION First Name:
Middle Initial:
DATE OF BIRTH:
Gender:
Last Season Played with Optimist: Home Address: City:
State:
Last Name: Male Female Previous Team/Coach Name: Zip:
Please list any allergies or medical conditions of the player that staff should be aware of: PARENT/GUARDIAN INFORMATION Parent(s)/Guardian(s) Name(s): EMAIL ADDRESS: Relationship to Player: Emergency Contact #: Cell #: Daytime # Would You Like to Receive TEXT ALERTS?* YES NO REGISTRATION INFORMATION (Year of Birth) FEES
2011 - 2012 2009 - 2010 1999 - 2008 WS OPTIMIST SCHOLARSHIP FUND - Optional
$75.00 $75.00 $95.00 $5.00
UNIFORM INCLUDED $20.00 $45.00
TOTAL
U7 & UNDER UNIFORM - 1 GOLD JERSEY / 1 PAIR BLACK SHORTS / 1 PAIR BLACK SOCKS U8-U18 UNIFORM - 1 GOLD JERSEY / 1 WHITE JERSEY / 1 PAIR BLACK SHORTS / 1 PAIR WHITE & 1 PAIR BLACK SOCKS U8 COMPLETER UNIFORM - 1 WHITE JERSEY / 1 PAIR WHITE SOCKS
TOTAL PAYMENT DUE CHECK # CREDIT CARD # EXPIRATION DATE: BILLING ADDRESS: CITY:
PAYMENT INFORMATION (CHECK ONE) CASH CREDIT CARD CVC CODE: STATE:
ZIP:
MAKE CHECKS PAYABLE TO OPTIMIST SOCCER and mail to 3051-B Trenwest Drive, Winston-Salem, NC 27103 Disclaimer: I/We hereby agree that Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, designated person(s) shall not be held liable for any injury or loss that I/We or my child(ren) may sustain whle participating in any activity whether sponsored or under the supervision of Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, officers or designated person(s). I/We agree to indemnify and hold harmless Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, officers or designated person(s) from any claim whatsoever. I/We have read, understand and agree to the Game Rules & Regulations as posted on the Optimist Website (WSOptimist.com). I/We have read, understand & agree to the Refund Policy as set forth and posted on the website (WSOptimist.com) by Optimist Club of Winston-Salem, Optimist Field Hockey & Optimist Soccer.
SIGNATURE:
DATE:
Registration Deadline: August 15, 2016 Late fee of $20 per player after 8/15/16 PLEASE PRINT. FORM MUST BE COMPLETED IN FULL TO GUARANTEE REGISTRATION.
PLAYER INFORMATION First Name:
Middle Initial:
DATE OF BIRTH:
Gender:
Last Season Played with Optimist: Home Address: City:
State:
Last Name: Male Female Previous Team/Coach Name: Zip:
Please list any allergies or medical conditions of the player that staff should be aware of: PARENT/GUARDIAN INFORMATION Parent(s)/Guardian(s) Name(s): EMAIL ADDRESS: Relationship to Player: Emergency Contact #: Cell #: Daytime # Would You Like to Receive TEXT ALERTS?* YES NO REGISTRATION INFORMATION (Year of Birth) FEES
2011 - 2012 2009 - 2010 1999 - 2008 WS OPTIMIST SCHOLARSHIP FUND - Optional
$75.00 $75.00 $95.00 $5.00
UNIFORM INCLUDED $20.00 $45.00
TOTAL
U7 & UNDER UNIFORM - 1 GOLD JERSEY / 1 PAIR BLACK SHORTS / 1 PAIR BLACK SOCKS U8-U18 UNIFORM - 1 GOLD JERSEY / 1 WHITE JERSEY / 1 PAIR BLACK SHORTS / 1 PAIR WHITE & 1 PAIR BLACK SOCKS U8 COMPLETER UNIFORM - 1 WHITE JERSEY / 1 PAIR WHITE SOCKS
TOTAL PAYMENT DUE CHECK # CREDIT CARD # EXPIRATION DATE: BILLING ADDRESS: CITY:
PAYMENT INFORMATION (CHECK ONE) CASH CREDIT CARD CVC CODE: STATE:
ZIP:
MAKE CHECKS PAYABLE TO OPTIMIST SOCCER and mail to 3051-B Trenwest Drive, Winston-Salem, NC 27103 Disclaimer: I/We hereby agree that Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, designated person(s) shall not be held liable for any injury or loss that I/We or my child(ren) may sustain whle participating in any activity whether sponsored or under the supervision of Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, officers or designated person(s). I/We agree to indemnify and hold harmless Optimist Club of Winston-Salem, Optimist Field Hockey, Optimist Soccer, its members, officers or designated person(s) from any claim whatsoever. I/We have read, understand and agree to the Game Rules & Regulations as posted on the Optimist Website (WSOptimist.com). I/We have read, understand & agree to the Refund Policy as set forth and posted on the website (WSOptimist.com) by Optimist Club of Winston-Salem, Optimist Field Hockey & Optimist Soccer.
SIGNATURE:
DATE:
