CF Empire Soccer Fall 2016 Soccer Registration Form - Amazon Web ...
*** This form must be submitted by July 31, 2016 to address at bottom. ***
CF Empire Soccer (formerly Empire United Soccer Association - E.U.S.A.) Check out our web site: www.empireunitedsoccerclub.org
Fall 2016 Soccer Registration Form PLEASE PRINT ALL INFORMATION! Age Group: (Office Use Only) _________ Player’s Last Name:__________________________________ First:_____________________ Nickname:____________ Street____________________________________________________________________________________________ City:_______________________________________________ State:________________ Zip:_____________________ Phone: ____________________ Date of Birth: ____/____/____ Shirt size (circle one): Youth-S Youth-M Youth-L Youth-XL School Grade (Fall 2016): ____ Gender (circle one): M F
Adult-S
Adult-M
Adult-L
Adult-XL
Years of soccer experience ________ PARENT/GUARDIAN Last Name:____________________ First:______________ Home Phone:______________ Cell Phone:______________ Last Name:____________________ First:______________ Home Phone:______________ Cell Phone:______________ Parent E-Mail Address: ___________________________________________________________________________ ADDITIONAL EMERGENCY CONTACT Last Name:____________________ First:______________ Phone:___________________ Relation:________________ MEDICAL / DOCTOR’S INFO Player’s Known Allergies:____________________________________________________________________________ Player’s Doctor:___________________________ Phone:___________________ Notes:__________________________ PERMISSION TO PARTICIPATE IN THE CF EMPIRE SOCCER PROGRAM: To the best of my knowledge, (enter player’s name)___________________________, is in good health and has my permission to participate in the CF Empire soccer program. I, the parent or legal guardian of the above named player, do hereby give my consent for him/her to participate in all of the soccer activities associated with the club. I do assume the entire risks and hazards incidental to the conduct of the soccer activities, transportation to and from the activities, and I do absolve, indemnify and hold harmless the Empire United Soccer Association, it’s organizers, coordinators, officers, sponsors, coaches, referees, and supervisors. I likewise release from responsibility any person transporting my child to or from soccer activities, which transportation I do hereby authorize.
MEDICAL RELEASE: Should my child become ill or sustain an injury, I authorize the designated coach to provide for medical treatment in an emergency. This would include the calling of a licensed physician for treatment, or the transportation or arrangement for transportation of the above named participant to a medical emergency room. I understand that an effort will be made to contact me in case of an emergency and that the cost, if any, for the treatment will be covered by myself or my medical insurance policy. I shall indemnify, hold free and harmless, assume liability for any costs and expenses of any kind that may have arisen or are alleged to have arisen out of participation in. SIGNATURE OF PARENT/GUARDIAN:____________________________________________________ DATE:_________________ Grow with the club by offering your support: [ ] Coach
[ ] Assistant coach [ ] Help with end of season party
[ ] Help with field preparation/tear down (once at beginning/end of season) Registration fee is non-refundable. Deadline: July 31, 2016 - $35.00 Late fees apply: July 31- Aug 31 - $45.00 st after Aug 31 - $55.00
Office use: Paid: Y N
Sorry but we cannot guarantee requests for coaches or teams. Mail this form with check made out to E.U.S.A to: CF Empire Soccer c/o Nicole Bongiorno 33 Clearview Place Binghamton, NY 13901
Amount:_______________ Check No: :_______________ Initials:_______________
CF Empire Soccer (formerly Empire United Soccer Association - E.U.S.A.) Check out our web site: www.empireunitedsoccerclub.org
Fall 2016 Soccer Registration Form PLEASE PRINT ALL INFORMATION! Age Group: (Office Use Only) _________ Player’s Last Name:__________________________________ First:_____________________ Nickname:____________ Street____________________________________________________________________________________________ City:_______________________________________________ State:________________ Zip:_____________________ Phone: ____________________ Date of Birth: ____/____/____ Shirt size (circle one): Youth-S Youth-M Youth-L Youth-XL School Grade (Fall 2016): ____ Gender (circle one): M F
Adult-S
Adult-M
Adult-L
Adult-XL
Years of soccer experience ________ PARENT/GUARDIAN Last Name:____________________ First:______________ Home Phone:______________ Cell Phone:______________ Last Name:____________________ First:______________ Home Phone:______________ Cell Phone:______________ Parent E-Mail Address: ___________________________________________________________________________ ADDITIONAL EMERGENCY CONTACT Last Name:____________________ First:______________ Phone:___________________ Relation:________________ MEDICAL / DOCTOR’S INFO Player’s Known Allergies:____________________________________________________________________________ Player’s Doctor:___________________________ Phone:___________________ Notes:__________________________ PERMISSION TO PARTICIPATE IN THE CF EMPIRE SOCCER PROGRAM: To the best of my knowledge, (enter player’s name)___________________________, is in good health and has my permission to participate in the CF Empire soccer program. I, the parent or legal guardian of the above named player, do hereby give my consent for him/her to participate in all of the soccer activities associated with the club. I do assume the entire risks and hazards incidental to the conduct of the soccer activities, transportation to and from the activities, and I do absolve, indemnify and hold harmless the Empire United Soccer Association, it’s organizers, coordinators, officers, sponsors, coaches, referees, and supervisors. I likewise release from responsibility any person transporting my child to or from soccer activities, which transportation I do hereby authorize.
MEDICAL RELEASE: Should my child become ill or sustain an injury, I authorize the designated coach to provide for medical treatment in an emergency. This would include the calling of a licensed physician for treatment, or the transportation or arrangement for transportation of the above named participant to a medical emergency room. I understand that an effort will be made to contact me in case of an emergency and that the cost, if any, for the treatment will be covered by myself or my medical insurance policy. I shall indemnify, hold free and harmless, assume liability for any costs and expenses of any kind that may have arisen or are alleged to have arisen out of participation in. SIGNATURE OF PARENT/GUARDIAN:____________________________________________________ DATE:_________________ Grow with the club by offering your support: [ ] Coach
[ ] Assistant coach [ ] Help with end of season party
[ ] Help with field preparation/tear down (once at beginning/end of season) Registration fee is non-refundable. Deadline: July 31, 2016 - $35.00 Late fees apply: July 31- Aug 31 - $45.00 st after Aug 31 - $55.00
Office use: Paid: Y N
Sorry but we cannot guarantee requests for coaches or teams. Mail this form with check made out to E.U.S.A to: CF Empire Soccer c/o Nicole Bongiorno 33 Clearview Place Binghamton, NY 13901
Amount:_______________ Check No: :_______________ Initials:_______________
