Norrisville Recreation Council - (White Hall, MD)

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Norrisville Recreation Soccer Registration Form

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

* Email:

* Gender:

Grade:

* Select Shirt Size:

* Select Sock Size:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

* Email:

* Home Phone:

Work Phone:

Cell Phone:

Should we use this Parent/Guardian for Emergency Contact?

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

Should we use this Parent/Guardian for Emergency Contact?

MEDICAL/EMERGENCY CONTACT INFORMATION (If Different then Parent/Guardian Above)

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

I would be happy to coach or assistant coach.

WAIVER INFORMATION

I certify that the individual named above is in good physical condition and is capable of participating in the named program. If medical attention beyond first-aid treatment is required, I understand that every attempt will be made to contact me at the emergency number provided. If contact with me is not possible, I give permission for medical attention to be administered. Furtermore, I hereby release, exonerate and discharge the organizers, officers, volunteers, coaches, officials, representative, employees, and agents from any and all actions and for any injuries or damages incurred while participating in, or traveling to and from, this program.

In accordance to Maryland law, I hereby acknowledge that I have received the information regarding concussions published by the United States Department of Health and Human Services Centers for Disease Control and Prevention (CDC). For additional information I understand that I may call 1-800-232-4636 or go to www.cdc.gov/concussion/HeadsUp/youth.html.

Please don't let your child miss out on playing because of the $65 fee. If assistance is needed please reach out to the soccer chair directly and we will make accommodations. No Child should miss the opportunity to play sports if they have the desire.

I/we agree with the above *

* indicates required fields