LIGHTHOUSE SOCCER CLUB - INHOUSE REGISTRATION

Date: ________

Check #: _____

Cash: ________

Total: ________

 
 


2010 REGISTRATION FORM

 

COST: $30.00 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: ___________________