NOTE: NASC IS A NOT-FOR- PROFIT
ORGANIZATION AND ANY MONEY PAID
TO
NASC IS NOT TAX EXEMPT
UNIFORM SIZE (Choose One)
YM
YL
AS
AM
AL
AXL
FUND RAISER
Fundraiser
Opt Out $25.00
I
will participate in the Fundraiser
PICTURE CONSENT
I
authorize NASC to post pictures on the web site.
VOLUNTEER INFORMATION
Please
contact me, I want to help.
I
can coach. Shirt Size:
Name:
If
licensed, please indicate your license:
Y F E
D C
B A
MEDICAL LIABILITY STATEMENT
To
induce the Neshannock Area Soccer Club to accept registration and permit
participation in NASC by the named individual, I/we, the parent(s) or
guardian(s) of said individual, hereby give my/our consent and agree to
release, indemnify, and hold harmless, its officials, coaches, and
representatives, from any claim arising out of injury to the named
individual. I/we, the undersigned parent(s) or guardian(s) of the
participant, a minor, do hereby authorize the coaches, assistant coaches,
or parents of team members acting in the capacity of activity
supervisors/vehicle drivers as agents for the undersigned to consent to
medical, surgical, or dental examination and/or treatment.
In
case of emergency, I/we authorize treatment for my/our child (name): at
any hospital. If there is an emergency and I/we cannot be reached, please
contact:
Name: Phone:
Relationship to Player: Who is hereby
authorized to act on my behalf.
LEGAL AUTHORIZATION FOR EMERGENCY CARE AND ACKNOWLEDGEMENT OF DISCLAIMER.
Does
your child have a physical, mental or emotional disability that you feel
the coach should be aware of? If so, please describe on the back of this
form.
__________________________________________________________ ______________________ Parent or Guardian
Signature Date
AGE GROUP (Check Appropriate box)
U-5
U-10
Travel (Last Year U-10 players only)
U-6
U-12
Travel
U-8
U-14
Travel
U-10
U-16
Travel
U-19
Travel
TRAVEL PLAYERS
Cup
Player
Photo
PlayerPass
Birth
Certificate
FEES:
Third Sibling is free of charge
$45.00
In-House (U5-U10) 8/24/07 To 9/1/07
$50.00 Early Registration up to 6/22/07
$75.00
registration 6/23/07 To 7/13/07
$100.00 Late Registration From 7/14/07 To 7/27/07
$25.00 for Jersey
FALL
REGISTRATION DEADLINE: June 22,
2007 early registration is closed for Travel-----and----- September
1, 2007 is closed for In-House. (Late fees will apply)
PARENTS: please sign below on the
areas which you intend to help with!!!
