Kirkwood Soccer Club
Kirkwood Soccer Club Kirkwood Soccer Club Urban League Player Registration Form – Winter 2015 Please return this completed form to your coach, along with a payment, payable to Kirkwood Soccer Club. Players must pay their fees in order to play or participate in any league at the Kirkwood Soccer Club. Fee Structure
U6 & U8 Age Groups = $40.00 U9, U11, U12, U14 & U16 Age Groups = $40.00 The above fees cover Kirkwood Soccer Club administrative costs, facility usage and Delaware Youth Soccer Association (DYSA) Insurance fees. Fees do not include referee fees and team uniform fees,.
Player Information Player Name (First - Last): Street Address: City:
State:
Zip:
Email Address: Birth Date: Emergency Phone #:
/ (
/
)
Phone #:
(
)
Cell Phone #:
(
)
School: Medical Restrictions:
I hereby give permission for my child to participate in Kirkwood Soccer Club programs and certify that he/she is physically fit and that the Kirkwood Soccer Club, Inc., its direct employees and coaches will not be held responsible for any accidents or injury during the course of the program. If any emergency care is required, I give my permission to Kirkwood Soccer Club to administer first-stage emergency treatment. I am granting Kirkwood Soccer Club permission to use his/her likeness, name, voice and words in television, radio, film, newspaper and magazines for communicating the activities of the Kirkwood Soccer Club. I accept full responsibility for any and all liability and release Kirkwood Soccer Club, its coaches, and officers from any financial liability due to injury otherwise.
Player Signature: _________________________________________________________________ Parent(s) Signature (If Under 18 Years Old): ________________________________________________ Team Name: _____________________________
Kirkwood Soccer Club 1220 River Road New Castle, DE 19720
Coach: _______________________________
Phone: (302) 322-4220 Fax: (302) 328-9235 Email: [email protected]
U6 & U8 Age Groups = $40.00 U9, U11, U12, U14 & U16 Age Groups = $40.00 The above fees cover Kirkwood Soccer Club administrative costs, facility usage and Delaware Youth Soccer Association (DYSA) Insurance fees. Fees do not include referee fees and team uniform fees,.
Player Information Player Name (First - Last): Street Address: City:
State:
Zip:
Email Address: Birth Date: Emergency Phone #:
/ (
/
)
Phone #:
(
)
Cell Phone #:
(
)
School: Medical Restrictions:
I hereby give permission for my child to participate in Kirkwood Soccer Club programs and certify that he/she is physically fit and that the Kirkwood Soccer Club, Inc., its direct employees and coaches will not be held responsible for any accidents or injury during the course of the program. If any emergency care is required, I give my permission to Kirkwood Soccer Club to administer first-stage emergency treatment. I am granting Kirkwood Soccer Club permission to use his/her likeness, name, voice and words in television, radio, film, newspaper and magazines for communicating the activities of the Kirkwood Soccer Club. I accept full responsibility for any and all liability and release Kirkwood Soccer Club, its coaches, and officers from any financial liability due to injury otherwise.
Player Signature: _________________________________________________________________ Parent(s) Signature (If Under 18 Years Old): ________________________________________________ Team Name: _____________________________
Kirkwood Soccer Club 1220 River Road New Castle, DE 19720
Coach: _______________________________
Phone: (302) 322-4220 Fax: (302) 328-9235 Email: [email protected]
