2011
FALL SOCCER REGISTRATION
K – 5th GRADE
BOYS AND GIRLS

NAME: ______________________________________________AGE ON Aug. 31, 2011 _____________

P.O. BOX _______________ CITY: _________________________________ SEX: F _____ M_____

CHILD HAS PLAYED FOR: _______ # OF YEARS BIRTHDATE: __________________________

CHILD IS IN ____________ GRADE E – MAIL __________________________________________

PHONE NUMBER: ______________________ EMERGENCY NUMBER: _______________________

DOES THE ABOVE NAMED HAVE ANY HEALTH PROBLEMS: YES______ NO______
IF YES PLEASE EXPLAIN: ______________________________________________________________
______________________________________________________________________________________

PLEASE RETURN THIS FORM TO CPRD BY Sept. 7th

Registration Fee: $10.00 Reversible Jersey: $10.00
Front desk staff will distribute jerseys at time of registration.
*If your child has a green and white reversible soccer jersey, they need not purchase another one!
(Coaches and Field supervisor will NOT have jerseys for sale)

I\We, the parents or legal guardian of the above named participant, do realize that with any sporting event there is a chance of injury. Knowing this, I/we give our full consent for our child’s participation in any or all CPRD fall soccer activities. I/we state that our child is physically fit to participate in the fall soccer program. I\we do agree that we will hold harmless CPRD, its director, supervisors, and coaches from any claim arising out of injury to my child as a result of participation. I/we give will also allow for my child's coach to give authorization for emergency medical treatment if I/we cannot be contacted.

Parents or Guardians Signature: _____________________________________________ Date: ________________

I am giving CPRD permission to use my child’s photograph in promotional displays (initial):___________

ALL PLAYERS and PARENTS!!!
Your coach will contact you with first practice time and location.

Your child plays for free if you coach!
Coaches meeting Thursday September 8th 6:00pm CPRD meeting Room

Coaching Name___________________________________ Phone__________________
Asst. Coach Name_________________________________ Phone__________________

All volunteers will be subject to a National Criminal/sex offender’s background check.


OFFICE USE ONLY

Receipt #___________Amount Received________Received by__________