DATE OF BIRTH:
WINSTON-SALEM OPTIMIST SOCCER PO BOX 25134, Winston-Salem, NC 27114 336-774-6773 WSOptimist.com Registration Deadline: AUGUST 15, 2017 Late fee of $20 per player after 9/1/17 PLEASE PRINT. FORM MUST BE COMPLETED IN FULL TO GUARANTEE REGISTRATION.
PLAYER INFORMATION First Name:
Middle Initial:
DATE OF BIRTH:
Gender:
Last Name: Male Female Previous Team/Coach Name:
Last Season Played with Optimist: Home Address: City: State: 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
REGISTRATION INFORMATION (BIRTH YEAR)
FEES
2013 - 2014 2011 - 2012 2000 - 2010 SCHOLARSHIP FUND - Optional
$75.00 $75.00 $95.00
NO UNIFORM
TOTAL
INCLUDED $25.00 $45.00 $5.00 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 PO BOX 25134, Winston-Salem, NC 27114 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 WinstonSalem, 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:
PLAYER INFORMATION First Name:
Middle Initial:
DATE OF BIRTH:
Gender:
Last Name: Male Female Previous Team/Coach Name:
Last Season Played with Optimist: Home Address: City: State: 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
REGISTRATION INFORMATION (BIRTH YEAR)
FEES
2013 - 2014 2011 - 2012 2000 - 2010 SCHOLARSHIP FUND - Optional
$75.00 $75.00 $95.00
NO UNIFORM
TOTAL
INCLUDED $25.00 $45.00 $5.00 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 PO BOX 25134, Winston-Salem, NC 27114 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 WinstonSalem, 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:
