Garden City Centennial Soccer Club Special Children's Registration Form |
APPLICATION
FOR PARTICIPATION IN SPECIAL SOCCER |
| Applicant's Name:____________________________________________________________________________ |
| (Please Print) | Last | First | Middle Initial | Date of Birth |
| I, the undersigned parent and/or guardian of the above named applicant (herein after referred to as the "Entrant"), hereby request permission for the Entrant to participate in the Special Soccer Program. |
| I represent and warrant to you that the Entrant is physically and mentally able to participate in Special Soccer and I submit herewith a subscribed medical certificate. |
| On behalf of the Entrant and myself, I acknowledge that the Entrant will be using facilities at his own risk and I, on my own behalf, hereby release, discharge and indemnify Special Soccer from all liability for injury to person or damage to property of myself and Entrant. |
| If I am not personally present at Special Soccer activities in which the Entrant is to compete, so as to be consulted in case of necessity, you are authorized on my behalf and at my account to take such measures and arrange for such medical and hospital treatment as you may deem advisable for the health and well-being of the Entrant. |
| Signature_____________________________________________________ Date___________________________ | ||
| Printed Name_________________________________________________________________________________ | ||
| Address_____________________________________________________________________________________ | ||
Street |
||
| _________________________________________________________________________________________________________________________________ | ||
| City | State | Zip |
| Day Phone ( )_____________________________ Evening Phone ( )_____________________________ | ||
| Emergency Contacts: Name___________________________________________________________________ | ||
| Day Phone ( )_____________________________ Evening Phone ( )_____________________________ | ||
| Entrant's Name____________________________________________________ | |
| (Please Print) | |
MEDICAL CERTIFICATE |
| I have examined the above named Entrant and, in my opinion, there is no physical reason why he or she should not participate in the Special Soccer program. Further information will be forwarded if required. Special medication and restrictions, if any, are specified on this application. |
| Date______________________ Physician__________________________________________________________ | ||
| Address________________________________________________________________________________________________________________________ | ||
Street |
||
| __________________________________________________________________________________________________________________________________ | ||
| City | State | Zip |
| Day Phone ( )_________________________________________ | ||
| Type of medical insurance, if any: | ||
| ___________________________________________________ INSURANCE I.D. #_________________________ | ||
| Special medication required: |
| ____________________________________________________________________________________________ |
| ____________________________________________________________________________________________ |
| ____________________________________________________________________________________________ |
| Restrictions, if any: |
| ____________________________________________________________________________________________ |
| ____________________________________________________________________________________________ |
| ____________________________________________________________________________________________ |
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