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LIGHTHOUSE SOCCER CLUB - INHOUSE REGISTRATION
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2010
REGISTRATION FORM
COST: $30.00 per player,INCLUDES T-SHIRT AND BALL MAKE CHECKS PAYABLE TO: MAIL TO: Visit us online at http://www.lighthousesoccer.org/
PLEASE Circle One: New Registrant Player Returning Registrant Last Name: ___________________________ First Name:
_______________________________ Address:
______________________________________________________________________ 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: 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: ___________________ |