Lake Gaston Soccer Association
Lake Gaston Soccer Association P.O. Box 8, South Hill, VA 23970 - 434-689-7000
Spring Rec Soccer (Ages 3-18) 2017 Registration Form Registration Fee: $50 After Mar 11, 2017: $75 NO REFUNDS – Register @ Bunny’s Field - 10AM Mar 4th & 11th Season begins March 25, 2017 - Last Day to Register: March 18, 2017 Fee includes Jersey, Shorts & Socks – Shin Guards are required
Please Print Information Participants Name:
Date of Birth:
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Sex: Male / Female Guardian Name: Address:
Home Phone: (
__________
_______
Email:___________________________________
_____________ Street/Route __) __ __- _____
Cell Phone: (
______ City/State/Zip )
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______
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____
Emergency Contact other than Guardian: Phone: (_ ) ) ***************************************************************************************** Authorization, Liability Statement, and Medical Consent •
• • • •
I understand I am responsible for providing accidental medical coverage for any injuries that could occur before, during, or after each practice and/or game. In the case of injury, I will not hold any personnel with the Lake Gaston Soccer Association liable for damages and/or cost incurred. I support and agree to abide by Lake Gaston Soccer Association's Zero Tolerance Policy I support and agree to abide by Lake Gaston Soccer Association's Concussion Policy I give consent in my absence for any qualified person/persons to provide emergency medical care deemed necessary and to abide by all rules established by the Lake Gaston Soccer Association. I further authorize Lake Gaston Soccer Association the use of my child’s image individually or in team photos for use on the leagues website and yearly publications. If I do not want my child’s image used I will notify the league.
Signature:
Other Pertinent Medical Information (allergies etc.)
__________________
**********THIS PROGRAM IS NOT AFFLIATED WITH MECKLENBURG COUNTY SCHOOLS********** CASH
Check #
Staff Initials:
Date
____ Amount Paid:
Spring Rec Soccer (Ages 3-18) 2017 Registration Form Registration Fee: $50 After Mar 11, 2017: $75 NO REFUNDS – Register @ Bunny’s Field - 10AM Mar 4th & 11th Season begins March 25, 2017 - Last Day to Register: March 18, 2017 Fee includes Jersey, Shorts & Socks – Shin Guards are required
Please Print Information Participants Name:
Date of Birth:
____
Sex: Male / Female Guardian Name: Address:
Home Phone: (
__________
_______
Email:___________________________________
_____________ Street/Route __) __ __- _____
Cell Phone: (
______ City/State/Zip )
_-
______
____
____
Emergency Contact other than Guardian: Phone: (_ ) ) ***************************************************************************************** Authorization, Liability Statement, and Medical Consent •
• • • •
I understand I am responsible for providing accidental medical coverage for any injuries that could occur before, during, or after each practice and/or game. In the case of injury, I will not hold any personnel with the Lake Gaston Soccer Association liable for damages and/or cost incurred. I support and agree to abide by Lake Gaston Soccer Association's Zero Tolerance Policy I support and agree to abide by Lake Gaston Soccer Association's Concussion Policy I give consent in my absence for any qualified person/persons to provide emergency medical care deemed necessary and to abide by all rules established by the Lake Gaston Soccer Association. I further authorize Lake Gaston Soccer Association the use of my child’s image individually or in team photos for use on the leagues website and yearly publications. If I do not want my child’s image used I will notify the league.
Signature:
Other Pertinent Medical Information (allergies etc.)
__________________
**********THIS PROGRAM IS NOT AFFLIATED WITH MECKLENBURG COUNTY SCHOOLS********** CASH
Check #
Staff Initials:
Date
____ Amount Paid:
