Franciscan Soccer Club PROGRAM REGISTRATION FORM

Franciscan Soccer Club TODAY’S DATE:

PROGRAM REGISTRATION FORM GENDER:

SCHOOL:

PLAYER NAME:

DATE OF BIRTH:

LAST OR CURRENT SELECT/REC TEAM:

PROGRAM:

PROGRAM LIST: Camp | Skillbuilders | Kickstarters | Juniors | Club Select Team |Rec Team

PROGRAM START:

EXPERIENCE:

None

Some

Select

PARENT NAME(S): ADDRESS 1: ADDRESS 2: EMAIL MOM:

Ph CELL:

EMAIL DAD:

Ph CELL:

ALLERGIES OR OTHER MEDICAL CONDITIONS: (1) ____________________________________________________________________________________ (2) ____________________________________________________________________________________ MEDICATIONS:

_________________________________________________________________________

LIABILITY WAIVER: By signing this form, I attest that my child is in good health and able to participate in the above program. I also understand that playing sports holds a degree of risk for injury to my child and agree not to hold the FSC or any of its hosting agents responsible should my child get injured from participation in the above FSC sports program.

DATE SIGNED:

PRINTED NAME: SIGNATURE:

PHOTO RELEASE: I grant to FSC the right to take photographs of my child in connection with the above-identified program. I authorize FSC, its assigns and transferees to copyright, use and publish the same in print and/or electronically.I agree that FSC may use such photographs of my child without identifying him/her by name and for any lawful purpose, including publicity, illustration, advertising, and Web content.

DATE SIGNED:

PRINTED NAME: SIGNATURE:

__________________________________________________________________________ __________________________________________________________________________ __________________________________________________________________________