Uniting the best of soccer for Mid-coast Maine

Pen Bay Soccer Club – home of the “Pilots”

www.penbaysoccerclub.org

              Pen Bay Soccer Club Fall 2010 Player Registration Form

 

 

Player has played         years for PBSC?             Player needs uniform:       Yes                No      (circle one)

 

Shirt Size:                                Short Size                               Shoe Size                               specify youth or adult

 

Player height & weight:                                                             Gender:                               

 

School attending in the fall:                                                    Fall 2010 Grade:                   

 

 

Player Information

 

Player Name:                                                                                      Date of Birth:                                    

 

            Physical Address:                                                                                                                              

 

Mailing Address if different:                                                                                                             

 

Home Phone Number:                                                  Mobile Number:                                           

 

Parent(s) Name(s):                                                                                                                            

 

Address if different then player:                                                                                                       

 

Home/Mobile if different then player:                                                                                               

 

Email address:                                                                                                            

 

We ask for active participation of all parents in our program. Check area(s) in which you would be willing to help.
If you have chosen Coach, Asst. Coach and/or Team Manager, you must complete a Risk Management Form for a background check to be completed 

Concessions	Concessions	Newsletter
Field Prep	Referee	Special Projects
Committee Member	Publicity	Donor
Fund Raising	Field Prep	Concessions
Newsletter

 

 

 

 

 

Does player have health insurance?                        Yes                  No

 

If yes: Policy Holder:                                                                                                                       

 

Group Number:                                           

 

 

Emergency Contact:                                                               Telephone:                                      

 

Player’s Doctor & Dr Phone Number                                                                                                

 

List medical problems/issues:                                                                                                          

 

Add special instructions for any medical condition listed:                                                                                                                                                                                                                                       

 

*Read the following information and check each box to indicate your agreement.

	I, the parent/guardian of the above-named player, a minor, agree that the player and I will abide by the rules and regulations of the USYSA, its affiliated organizations and its sponsors ("USYSA Parties"). In consideration of the player's participation in the soccer league programs and activities of the USYSA Parties (the "Program"), I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player’s participation in the Programs including, without limitation, player’s transportation to/from any Program, which transportation is hereby authorized. I further grant the USYSA Parties the right to use the player’s name, picture and/or likeness in printed, broadcast, and other material concerning the Programs provided such use is related to the player’s status as a participant in the Programs.
	As the parent or legal guardian of the above-named player, I hereby give consent for emergency care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.
	Recognizing that adults are role models for all of our players, I/we pledge not to smoke or to use tobacco in proximity to any fields being used for youth soccer activities.

 

 

Please mail this completed form along with a check for $80 to:

 

 

Rick Bresnahan

Pen Bay Soccer Club

721 Camden Road * Hope, ME * 04847

207-236-2655

Rickb4@myfairpoint.net