Registration Form & Medical Release Form
Player’s Name: ________________________________________ Date of Birth: __________________
Address: ______________________________________________________________
City: ___________________ State: ___________ Zip Code: ___________________
Check one: Keeper____
Cell Phone: _________________ Home Phone: ____________ Emergency Phone: ________________
Email address: _________________________________________
Division: Male____(U9/U10)____ (U11/U12) ____ (U13/U14) ____ (U15/U16) ____ (U17/U19)
Female____(U9/U10)____ (U11/U12) ____ (U13/U14) ____ (U15/U16) ____ (U17/U19)
College Division: Male____ Female____
Current Team (Note Age Group):______________________ Home Association: __________________
Team Coach: _____________________________ Phone number: ___________________________
This release is made to allow my child to participate in Plainfield First Annaul Panthers 3v3 and Goalie Wars Challange. I recognize that my signature on this release is a condition of your permitting my child to participate. I certify that my child is in excellent physical health, and has my permission to participate in strenuous and hazardous physical activities, including the soccer to be played at any and all Plainfield Programs. I certify that there are no physical limits to my child’s participation. I grant permission for my child to receive emergency medical treatment if needed. I hereby release and discharge Plainfield Soccer Club, their agents, officers, employees, representatives and successors, the officials conducting the event, and any other sponsoring organization from any and all liability, claims, demands and causes of action for personal injury, property damage, and/or other loss suffered by my child in connection with his/her participation in any and all Plainfield Soccer Club Programs.
I represent that I am a parent/guardian of the minor named above and I agree that the grant and released contained herein blinds me and my child to all its terms.
Signature of Parent /Guardian and Date
__________________________________________________________________________________________
Send Payment to:
Plainfield Soccer Club, P.O. 215 Central Village, CT 06332-0215
Please feel free to contact us with any questions.
[email protected]