KCPE Rec Flyer 2015
BELTON PARKS & RECREATION/ KC PRIME ELITE SOCCER CLUB
2015 Fall Soccer Registration Make checks payable to: Belton Parks & Recreation
Last Name:_______________________________ First Name:_________________________ MI:________ Address:__________________________________________
City:_______________________________
State:________ Zip Code:_____________ Phone:_____________________ Mobile____________________ Birth Date:_________________ (MM/DD/YYYY)Sex: ____M _____F
Activity #: 126090
Player resides with: _____Father _____Mother _____Both _____Legal Guardian Father's Name:________________________ Phone:____________________ E-mail*:___________________________________ Mother's Name:________________________ Phone:____________________ E-mail*:___________________________________ *Email addresses will be used by Belton Parks & Recreation & KC Prime Elite Soccer Club for communication purposes.
List any medical problem or prohibition for Player:_____________________________________________________________ Emergency Contact Person (other than parents) Name:__________________________________________________________ Relationship:_____________________________
Phone (H) :__________________ Phone (W) :_______________________
Division: (please check one) Age Youth Pre-Academy 3-4 Years Youth Academy 5-6 Years U8 7 Years U10 8-9 Years U12 10-11 Years
Early Bird Fee $50 $70 $80 $80 $80
(Before Aug. 4)
(Aug. 5 – Aug. 17)
Fee $60 $80 $90 $90 $90
Jersey Size: (please check one) YXS (2-4) YS (6-8) YM (10-12) YL (14-16)
AS AM AL AXL
Pre Academy (3&4 year olds) training sessions will be held on Monday Evenings ONLY from 5:45-6:30pm for 5 weeks Academy training sessions will be held on Monday Evenings 6:30-7:15pm and Games will be played Saturdays at 9am for 6 weeks Both Youth Pre-Academy and Youth Academy Sessions will begin Monday September 14th.
Coaches Name (U8-U12 Divisions):__________________________________ Providing a coaches name, does not guarantee placement on that coach’s team. Requests are considered as we seek division balance.
Division: ________Coed ________Girls _______ Place this returning player on a different team. (player will not be placed on the same team as last season) PARENTAL SUPPORT (Mark all that apply) _____COACH
_____TEAM MANAGER
_____SPONSOR
_____TEAM PARENT
LIABILITY RELEASE (MUST be signed by parent or legal guardian of player) I, the parent or legal guardian of the above registered player, a minor, agree that I and the player will abide by the rules and regulations of the USYSA, its affiliated organizations, and sponsors ("USYSA Parties"). In consideration of the player's participation in the soccer Programs and activities of the USYSA Parties (the Programs), I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player's participation in the Programs including, without limitation, player's transportation to/from any program, which transportation is hereby authorized. I future grant the USYSA Parties the right to use the Player's name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player's status as a participant in the Program.
SIGNATURE_____________________________________ DATE________________________
Print Name_______________________________________
www.beltonparks.org or www.kcprime.org
2015 Fall Soccer Registration Make checks payable to: Belton Parks & Recreation
Last Name:_______________________________ First Name:_________________________ MI:________ Address:__________________________________________
City:_______________________________
State:________ Zip Code:_____________ Phone:_____________________ Mobile____________________ Birth Date:_________________ (MM/DD/YYYY)Sex: ____M _____F
Activity #: 126090
Player resides with: _____Father _____Mother _____Both _____Legal Guardian Father's Name:________________________ Phone:____________________ E-mail*:___________________________________ Mother's Name:________________________ Phone:____________________ E-mail*:___________________________________ *Email addresses will be used by Belton Parks & Recreation & KC Prime Elite Soccer Club for communication purposes.
List any medical problem or prohibition for Player:_____________________________________________________________ Emergency Contact Person (other than parents) Name:__________________________________________________________ Relationship:_____________________________
Phone (H) :__________________ Phone (W) :_______________________
Division: (please check one) Age Youth Pre-Academy 3-4 Years Youth Academy 5-6 Years U8 7 Years U10 8-9 Years U12 10-11 Years
Early Bird Fee $50 $70 $80 $80 $80
(Before Aug. 4)
(Aug. 5 – Aug. 17)
Fee $60 $80 $90 $90 $90
Jersey Size: (please check one) YXS (2-4) YS (6-8) YM (10-12) YL (14-16)
AS AM AL AXL
Pre Academy (3&4 year olds) training sessions will be held on Monday Evenings ONLY from 5:45-6:30pm for 5 weeks Academy training sessions will be held on Monday Evenings 6:30-7:15pm and Games will be played Saturdays at 9am for 6 weeks Both Youth Pre-Academy and Youth Academy Sessions will begin Monday September 14th.
Coaches Name (U8-U12 Divisions):__________________________________ Providing a coaches name, does not guarantee placement on that coach’s team. Requests are considered as we seek division balance.
Division: ________Coed ________Girls _______ Place this returning player on a different team. (player will not be placed on the same team as last season) PARENTAL SUPPORT (Mark all that apply) _____COACH
_____TEAM MANAGER
_____SPONSOR
_____TEAM PARENT
LIABILITY RELEASE (MUST be signed by parent or legal guardian of player) I, the parent or legal guardian of the above registered player, a minor, agree that I and the player will abide by the rules and regulations of the USYSA, its affiliated organizations, and sponsors ("USYSA Parties"). In consideration of the player's participation in the soccer Programs and activities of the USYSA Parties (the Programs), I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player's participation in the Programs including, without limitation, player's transportation to/from any program, which transportation is hereby authorized. I future grant the USYSA Parties the right to use the Player's name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player's status as a participant in the Program.
SIGNATURE_____________________________________ DATE________________________
Print Name_______________________________________
www.beltonparks.org or www.kcprime.org
