RICHMONDTOWN SOCCER CLUB

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Under 8, 10, 12 &14
No Photo for Under 6
Registration 4 years to 14 years
 
Please Print all Information.  Use a separate form for each child.
Fee is $100 ($150 after 5/31/07) made payable to Richmondtown Soccer Club.  NO CASH!
Player's Name (Last)                                                          (First)                                
Mailing Address (Street)                                                        S. I., N.Y.                                 
E-Mail Address _________________________________________________________________
Telephone:                                                  Date of Birth:                             o Male o Female
Team last Season:                                                    
Does child play for another Club/League?   o Yes    o No
                        If so, what Club/League?  ___________________________
Parent's or Guardian's first name (s)                                /                        
**** Your Child is Not Guaranteed to be Placed on the Same Team ****

EMERGENCY INFORMATION
Name of Parent/Guardian ____________________________________________
Telephone: _________________  Alternate Telephone: _________________
Medical Information:  Detail and Handicaps or Medical Conditions we should know about.

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Parent Participation: PLEASE GET INVOLVED FOR THE CHILDREN
Interested in coaching?  o Yes  o No  Assistant Coach?  o Yes  o No    Team Mother? o Yes   o No

If Yes, tell us your name: _______________________

No soccer experience is necessary.  You will have the assistance of experienced coaches and the opportunity to obtain a coaching license through Richmondtown Soccer Club.

Parent/Guardian Consent:
I, THE UNDERSIGNED PARENT OR GUARDIAN OF THE REGISTRANT, A MINOR, AGREE THAT WE WILL ABIDE BY ALL RULES/LAWS/REGULATIONS, SPECIFICALLY SOCCER, AND ALL AFFILIATED ORGANIZATIONS AND SPONSORS, RECOGNIZING THE RISK OF INJURY WITH SPORT PARTICIPATION AND IN CONSIDERATION OF OUR ACCEPTING FOR THIS PROGRAM, I/WE HEREBY RELEASE AND DISCHARGE AND/OR INDEMNIFY RICHMONDTOWN SOCCER CLUB, AFFILIATED ORGANIZATIONS, SPONSORS, THEIR EMPLOYEES AND ASSOCIATED PERSONS OF THIS PROGRAM AGAINST ANY CLAIM BY OR ON BEHALF OF THE REGISTRANT INCLUDING BUT NOT LIMITED TO TRANSPORTATION TO AND FROM ACTIVITIES, WHICH TRANSPORTATION IS HEREBY AUTHORIZED.

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                  DATE                                                             PARENT/GUARDIAN SIGNATURE