DATE OF BIRTH:
WINSTON-SALEM OPTIMIST FIELD HOCKEY OPTIMIST FIELD HOCKEY - SPRING 2017 PO BOX 25134, Winston-Salem, NC 27114 336-774-6773 WSOptimist.com REGISTRATION DEADLINE: FEBRUARY 15, 2017 LATE FEE OF $20/PLAYER AFTER 2/15/17 PLEASE PRINT. FORM MUST BE COMPLETED IN FULL TO GUARANTEE REGISTRATION. PLAYER INFORMATION First Name: Middle Initial: Last Name:
DATE OF BIRTH:
Gender:
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
REGISTRATION FEE (per player) UNIFORM FEE (per player) FIELD HOCKEY KIT* (per player) WS OPTIMIST SCHOLARSHIP FUND - Optional
NO FEES
TTL Amount
$95.00 $75.00 $75.00 $5.00
*Field Hockey Kit Includes 24-36" Field Stick, Shin Guards, Ball & Mouth Guard. Any stick over 36" must be purchased separately.
TOTAL PAYMENT DUE PAYMENT INFORMATION (CHECK ONE)
CHECK # CREDIT CARD # EXPIRATION DATE: BILLING ADDRESS: CITY:
CASH
CREDIT CARD CVC CODE: STATE:
ZIP:
MAKE CHECKS PAYABLE TO OPTIMIST FIELD HOCKEY 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:
DATE OF BIRTH:
Gender:
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
REGISTRATION FEE (per player) UNIFORM FEE (per player) FIELD HOCKEY KIT* (per player) WS OPTIMIST SCHOLARSHIP FUND - Optional
NO FEES
TTL Amount
$95.00 $75.00 $75.00 $5.00
*Field Hockey Kit Includes 24-36" Field Stick, Shin Guards, Ball & Mouth Guard. Any stick over 36" must be purchased separately.
TOTAL PAYMENT DUE PAYMENT INFORMATION (CHECK ONE)
CHECK # CREDIT CARD # EXPIRATION DATE: BILLING ADDRESS: CITY:
CASH
CREDIT CARD CVC CODE: STATE:
ZIP:
MAKE CHECKS PAYABLE TO OPTIMIST FIELD HOCKEY 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:
