Elite Academy FC
St Pauls Soccer Association Inc
Elite Academy FC TRAVEL SOCCER PROGRAM REGISTRATION FORM 2018 SPRING 648 N Old Stage Road St Pauls, NC 28384 (910).616.3872 www.eliteacademyfc.org
PLAYER INFORMATION New or Returning Player*: (check one)
* required field
[ ] New
** at least one field required
[ ] Returning
Has the Player Previously played with our program*: (check one)
[ ] Yes
[ ] No
Does the player have a sibling in the same division*: (check one)
[ ] Yes
[ ] No
Player Name*: _____________________________________________________ Date of Birth*: _________________ Address*: __________________________________ City*: __________________ State*: ______ Zip*: ____________ Home Phone**: ______________________________ Mobile Phone**: __________________________________ e-mail*: __________________________________________ Height*: ______________ Weight*: ________________ Current School*: ____________________________________________________ Current Grade*: _____________ Years of Soccer Experience*: ___________ Shirt Size*: (circle one) Shorts Size*: (circle one)
S
M
L
XL
YM
YL
S
Socks Size*: (circle one)
M
L
XL
S
M
L
If applicable, list any medical conditions that we may need to be aware of: ____________________________________ __________________________________________________________________________________________________
PARENT INFORMATION Parent Name*: __________________________________________________ Relation*: ________________________ Gender*: (check one)
[ ] Male
[ ] Female
Age*: ____________
Emergency Contact Number #1**: ____________________________________________ Emergency Contact Number #2**: ____________________________________________ e-mail*: __________________________________________________ Parent Volunteer/Support Type Requested*: (check any type that you would like to volunteer for) We are constantly looking for parental support for our program. Consider becoming a volunteer on some match days and for specific teams to help with our organization. Please select any of the following that you would be interested in. [ ] Coach [ ] Assistant Coach [ ] Concession [ ] Fundraising
[ ] Manager
[ ] Referee
[ ] Board Member
FOR CLUB/LEAGUE USE ONLY Date Received: ______________________________ Copy of Birth Certificate Received: ____________________________________ Payment Received: ___________________________________ Cash Payment or Check #: _______________________________________
[ ] Fields
Medical Consent/Hold Harmless Every player within your organization MUST have a parent or guardian sign off on this statement. If you have any questions, please contact your SAY Administrator prior to completing this agreement.
________________________________________________________________________________________ Consent for Emergency Medical Treatment We, the Parents of, give permission for emergency medical treatment of our child for illness or accident if we cannot first be contacted. Emergency Parent or Guardian: Name: Phone:
Office:
Mobile:
Email: Emergency Secondary Contact: (other than parent) Name: Phone:
Office:
Mobile:
Email: Relationship: Does your child have any allergies or require special medication:
Yes:
No:
Explanation:
_____________________________________________ Signature(Parent/Guardian)
________________________________________ Date
Hold Harmless Statement WE HEREBY AGREE THAT THE SOCCER ASSOCIATION FOR YOUTH (SAY) ITS MEMBERS, COACHES OR OFFICERS SHALL NOT BE LIABLE FOR ANY INJURY OR LOSS IN WHICH MY CHILD MAY SUSTAIN WHILE PARTICIPATING IN ACTIVITIES OF ANY KIND WHETHER SPONSORED BY OR UNDER THE SUPERVISION OF SAY AND WE AGREE TO IDEMNIFY AND TO HOLD HARMLESS SAY, IT’S MEMBERS, COACHES AND OFFICERS OR DESIGNATES OF ANY KIND FROM ANY CLAIM WHATSOEVER.
_____________________________________________ Signature(Parent/Guardian)
________________________________________ Date
This statement CANNOT be altered to include your District, SAYArea, SAY Organization, City, etc. If you need an additional statement that includes any other entity, then simply add another statement beneath this statement on your player registration form, electronic registration form, etc. Our insurance carrier dictates this.
Version 12/16
Elite Academy FC TRAVEL SOCCER PROGRAM REGISTRATION FORM 2018 SPRING 648 N Old Stage Road St Pauls, NC 28384 (910).616.3872 www.eliteacademyfc.org
PLAYER INFORMATION New or Returning Player*: (check one)
* required field
[ ] New
** at least one field required
[ ] Returning
Has the Player Previously played with our program*: (check one)
[ ] Yes
[ ] No
Does the player have a sibling in the same division*: (check one)
[ ] Yes
[ ] No
Player Name*: _____________________________________________________ Date of Birth*: _________________ Address*: __________________________________ City*: __________________ State*: ______ Zip*: ____________ Home Phone**: ______________________________ Mobile Phone**: __________________________________ e-mail*: __________________________________________ Height*: ______________ Weight*: ________________ Current School*: ____________________________________________________ Current Grade*: _____________ Years of Soccer Experience*: ___________ Shirt Size*: (circle one) Shorts Size*: (circle one)
S
M
L
XL
YM
YL
S
Socks Size*: (circle one)
M
L
XL
S
M
L
If applicable, list any medical conditions that we may need to be aware of: ____________________________________ __________________________________________________________________________________________________
PARENT INFORMATION Parent Name*: __________________________________________________ Relation*: ________________________ Gender*: (check one)
[ ] Male
[ ] Female
Age*: ____________
Emergency Contact Number #1**: ____________________________________________ Emergency Contact Number #2**: ____________________________________________ e-mail*: __________________________________________________ Parent Volunteer/Support Type Requested*: (check any type that you would like to volunteer for) We are constantly looking for parental support for our program. Consider becoming a volunteer on some match days and for specific teams to help with our organization. Please select any of the following that you would be interested in. [ ] Coach [ ] Assistant Coach [ ] Concession [ ] Fundraising
[ ] Manager
[ ] Referee
[ ] Board Member
FOR CLUB/LEAGUE USE ONLY Date Received: ______________________________ Copy of Birth Certificate Received: ____________________________________ Payment Received: ___________________________________ Cash Payment or Check #: _______________________________________
[ ] Fields
Medical Consent/Hold Harmless Every player within your organization MUST have a parent or guardian sign off on this statement. If you have any questions, please contact your SAY Administrator prior to completing this agreement.
________________________________________________________________________________________ Consent for Emergency Medical Treatment We, the Parents of, give permission for emergency medical treatment of our child for illness or accident if we cannot first be contacted. Emergency Parent or Guardian: Name: Phone:
Office:
Mobile:
Email: Emergency Secondary Contact: (other than parent) Name: Phone:
Office:
Mobile:
Email: Relationship: Does your child have any allergies or require special medication:
Yes:
No:
Explanation:
_____________________________________________ Signature(Parent/Guardian)
________________________________________ Date
Hold Harmless Statement WE HEREBY AGREE THAT THE SOCCER ASSOCIATION FOR YOUTH (SAY) ITS MEMBERS, COACHES OR OFFICERS SHALL NOT BE LIABLE FOR ANY INJURY OR LOSS IN WHICH MY CHILD MAY SUSTAIN WHILE PARTICIPATING IN ACTIVITIES OF ANY KIND WHETHER SPONSORED BY OR UNDER THE SUPERVISION OF SAY AND WE AGREE TO IDEMNIFY AND TO HOLD HARMLESS SAY, IT’S MEMBERS, COACHES AND OFFICERS OR DESIGNATES OF ANY KIND FROM ANY CLAIM WHATSOEVER.
_____________________________________________ Signature(Parent/Guardian)
________________________________________ Date
This statement CANNOT be altered to include your District, SAYArea, SAY Organization, City, etc. If you need an additional statement that includes any other entity, then simply add another statement beneath this statement on your player registration form, electronic registration form, etc. Our insurance carrier dictates this.
Version 12/16
