Registration Form
Registration
forms are accepted every Thursday (6-8pm) and Saturday (9am-12pm) for the entire
month at
Email:
portlandsoccerclub@yahoo.com
Web site:
www.portlandsoccerclub.com
Player Information
Player’s Name:
(First, Middle & Last)
Address:
(Street, City, State, & Zip Code)
Home Phone:
Date of Birth:
Age:
Preferred way of
communication:
(Ex. Texting, e-mail, phone call to home, phone call to cell)
Uniform Size:
Shirt: Youth __XS __S __M __L or Adult __S __M __L __XL
Shorts: Youth __XS __S __M __L or Adult __S __M __L __XL
Gender:
___ Male ___ Female
Number of years playing soccer:
Brothers/Sisters playing: Names & Ages:
Parent/Guardian Information
Mothers Name/Legal Guardian’s
Name:
Email:
Work #:
Home #:
Cell #:
Father’s Name/Legal Guardian’s
Name:
Email:
Work #:
Home #:
Cell #:
Registration Fees:
3yr olds=$45 U-6=$45 U-8=$60
U-10=$65 U-12=$65 U-15=$80
(The U in
each age group mean under. The child would have to be under that age to
play in that age group. Example: U-6 is 4 and 5 year olds.
Children must play in current age group.
They can be moved up to next age group but not moved back. Example: 3yr old can
move up to U-6 but 6yr old can’t move to U-6 they will be U-8)
Medical Release Form
As the parent/legal guardian of ________________________, I request that in my
absence, the above-named player be admitted to any hospital or medical facility
for diagnosis and treatment. I
request and authorize physicians, dentists, and staff, duly licensed as Doctors
of Medicine or Doctors of Dentistry or other such licensed technicians or
nurses, to perform any diagnostic procedures, treatment procedures, operative
procedures and x-ray treatment of the above minor.
I have not been given a guarantee as to the results of examination or
treatment. I authorize the hospital
or medical facility to dispose of any specimen or tissue taken from the above
named player.
Date
of Players Birth
/ /
Date of last Tetanus Booster
___/___/___
Known allergies of this player,
including any allergies to medicine
_
_____________________________________________________
__
Any other medical problems which should
be noted __________
__
_____________________________________________________________________
Family
Physician ___________________
Phone (___) ________________
Name
of Parent/Guardian
_________________________________________
Address
____________________________________________________________
City/State/Zip
______________________________________________________
Phone (Home) ______________ (Work)
_______________ (Cell) __________
Person
responsible for charges (if different from above)
Address
_____________________________________________________________
City/State/Zip
_______________________________________________________
Phone (Home) ____________ (Work)
_______________ (Cell) _____________
Person
to notify if parent/guardian is unavailable
_________________
Phone (Home) ____________ (Work)
_______________ (Cell) ____________
Insurance carrier
____________________________ Policy # _____________
Signature of Parent/Guardian
_______________________________________
Parent/Guardian Waiver and Consent
In
consideration and exchange for the City of Portland, Tennessee’s allowing
Participant to participate in league sponsored sports activities on City
Property. Participant does Hereby,
Permanently and completely, waive and release any and all claims and causes of
action for Personal injuries or property damage which participant might have or
hereafter acquire against City arising as a result of such participation.
Participant shall not hold city responsible for the condition of the property,
equipment, the operation of the league, the conduct of the participants,
coaches, officials, spectators or any other cause which might give rise to
injury or damage to participant.
Participant acknowledges that sports activities may be physically hazardous and
voluntarily assumes the risk of such injury.
If participant is a minor or under a legal disability, this wavier is
executed on behalf of participant by participant’s custodial parent or legal
guardian. I also understand that no
refunds will be given. (The only exception being if the applicant is injured,
becomes ill, or moves out of the areas prior to the beginning of practice)
Signature
of Parent/Guardian:
Date:
Parent Volunteer
The
Portland Soccer Club is operated with people who volunteer their time for the
sole purpose of providing a safe and fun recreational soccer environment for our
children and the children of our community.
Volunteers are necessary for the operation of our club.
You are vital to the success of PSC!
In an
effort to keep our registration fees low, we ask each parent to VOLUNTEER
at least ONE HOUR during the season.
Please indicate where you can volunteer.
Training is available.
Volunteer # 1:
Name:
Relationship to player
Preferred
way of communication:
(Ex. Texting, e-mail, phone call to home, phone call to cell)
Email:
Home #:
Cell #:
_____Coach _____ Assistant Coach _____ Concession Stand
_____ Referee (This is a paying position) _____Field Maintenance Day
_____Opening Day Set Up _____ Closing Day Set Up
_____ Board member (Check for position availability) _____ Unable to Volunteer
Volunteer # 2:
Name:
Relationship to player
Preferred
way of communication:
(Ex. Texting, e-mail, phone call to home, phone call to cell)
Email:
Home #:
Cell #:
_____Coach _____ Assistant Coach _____ Concession Stand
_____ Referee (This is a paying position) _____Field Maintenance Day
_____Opening Day Set Up _____ Closing Day Set Up
_____ Board member (Check for position
availability)
_____ Unable to Volunteer