|
LIGHTHOUSE SOCCER CLUB -
INHOUSE REGISTRATION
SPRING 2008 REGISTRATION
FORM
COST: $25.00
per player,INCLUDES T-SHIRT AND BALL
MAKE CHECKS PAYABLE TO:
Lighthouse Soccer Club
MAIL TO: Lighthouse Soccer
Club
PO Box 11562 Philadelphia,
PA 19116
Visit us online at http://www.lighthousesoccer.org/
PLEASE Circle One:
New
Registrant Player
Returning Registrant
Last Name:
___________________________ First Name:
_______________________________
Address:
______________________________________________________________________
Home
Phone #: (_____) _______-__________
Cell
Phone #: (_____) _______-__________
City:
_________________________________ State: _______
Zip:_____________________
Birthdate:
_____/_______/_________ Sex:
M F Email:
__________________________
School Child Attends:
___________________________________________________________
Parent/Guardian Name
(PRINT):
__________________________________________________
Medical Problems:
______________________________________________________________
Years of Soccer Experience:
_______________________________________________________
Please Circle One Area In
Which You Can Help:
Coach Assistant Coach Snackstand
________________________________________________________________________
MEDICAL INSURANCE:
Lighthouse
Soccer Club requires that you disclose a primary medical insurance carrier. Failure to comply will disqualify
applicant from participating in Lighthouse
Soccer Club programs.
Carrier Name:
________________________________________ Policy #:
___________________________________
RELEASE
STATEMENT
NOTE: The statement should be
signed by a parent/guardian for minor player, an adult player himself; coach for
himself; and administrator for himself. I, the parent/guardian of the
registrant, a minor, or adult registrant of legal age, agree that I and the
registrant will abide by the rules of the EPYSA, it’s affiliated organizations
and sponsors. Recognizing the
possibility of the physical injury associated with soccer and in consideration
for the EPYSA accepting the registrant for its soccer programs and activities
(the “Programs”). I herby release,
discharge and/or otherwise indemnify the EPYSA, its affiliated organizations,
and sponsors, their employees and associated personnel, including the owners of
the fields and facilities utilized for the Programs, against any claim by on or
behalf of the registrant as a result of the registrant’s participation in the
Programs, and/or being transported to or from the same, which transportation I
herby authorized.
PARENT/GUARDIAN OR ADULT
SIGNATURE: ___________________________________________
DATE:
___________________
|