2009-10 U6 - U10 CLINIC REGISTRATION FORM
All information is required to register!
Player Information
First Name
Last Name
Date of Birth
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2009
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2010
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Address
City
State
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AK
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AZ
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AR
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CA
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CO
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CT
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DE
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DC
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FL
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GA
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HI
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ID
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IL
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IN
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IA
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KS
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KY
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LA
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ME
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MD
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MA
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MI
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MN
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MS
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MO
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MT
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NE
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NV
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NH
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NJ
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NM
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NY
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NC
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ND
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OH
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OK
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OR
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PA
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RI
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SC
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SD
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TN
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TX
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UT
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VT
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VA
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WA
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WV
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WI
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WY
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Zip
Email Address #1
Email Address #2
Best phone number to be reached at?
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Parent Information - Mother
First Name
Last Name
Work Phone - 7025555555 - (No dashes)
Mobile Phone - 7025555555 - (No dashes)
Parent Information - Father
First Name
Last Name
Work Phone - (No dashes)
Mobile Phone - (No dashes)
Soccer Information
Registering for what age group?
Boys:
BU6
BU7
BU8
BU9
BU10
Girls:
GU6
GU7
GU8
GU9
GU10
Last team played for?
Medical Information
Any known health problems?
Parent/Guardian Consent Information
Parent/Guardian Consent:
I do hereby expressly assume all of the risks which attend the game of soccer and any other sports or related activities, including but not limited to physical contact and physical injuries. I agree to indemnify and hold members including but not limited to any adjoining facilities and Neusport Football Club from any and all claims, suits, or proceedings arising allegedly or in reality out of the acts of omission and participation of the undersigned in any or related activity. I also agree to all rules and regulations of the Neusport Football Club.
Consent for Medical Treatment (Minor):
As the parent or legal guardian of the above player, I hereby give consent for emergency medical care prescribed by a duly licensed doctor of medicine or dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of this minor, named above.
Parent/Guardian Acknowledgement:
By checking this box, you agree to use an electronic signature in lieu of a paper-based signature. You understand that electronic signatures, just like your signing a piece of paper, are legally binding in the United States and in other countries. You further agree not to electronically sign any form without first reading it and ensuring you have accurately filled out the form to the best of your knowledge.
Date:
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