Eureka Soccer Registration Form

Player Name

Gender

Address

Home phone #

Format: (000) 000-0000.

Cell Phone

Format: (000) 000-0000.

Email

example@example.com

Parent or Legal Guardian Name

Age of Child

Grade

Name and phone number of person to contact in case of an emergency: (secondary to parent/guardian)

Format: (000) 000-0000.

Name

Tee Shirt Size

Medical Information

List all special health concerns:

Medication Taken:

List all known allergies:

Activity restrictions

All players must wear these items during games: black socks, black shorts, shin guards, and Eureka Soccer Club tee shirt (provided). You can buy black shorts, socks, and shin guards at any store

$12.00 Soccer Fee (per child) This will help cover the cost for use of the equipment and food for the tournament, etc. (Mandatory Fee)

As legal guardian of the named participant, knowing the risks involved, I give my permission for him/her to participate in all activities for said program. In addition, I authorize all instructors, directors, coaches, and assistants to obtain medical care for my son/daughter in the event that such is needed. Further permission is hereby granted to the licensed physician or accredited hospital and their associates to perform any medical and/or surgical procedures deemed essential to the treatment of the above named participant. I further agree to be responsible for payment of such care.

(Scholarships are available as needed. Please contact Eureka County Juvenile Probation for more information. No Child will be turned away)

Signature of Parent or Legal Guardian

Date