Return Form & Payment to:

HHYSC

PO BOX 521

CICERO, IN 46034

Hamilton Heights

Youth Soccer Club

Player’s Name (Please Print)

First ______________________ Middle _______________ Last __________________

Address ________________________________________ City_______________ State_____ Zip_______

Phone ( ____) _____-___________Date of Birth-Mo______ Day____ Yr_____ Age_____ Sex: M F

School System_________________________ Grade______ Parent E-mail___________________________

Father (First) _____________________________ (Last) _________________________________________

Work Place ____________________________________ Phone ___________________________________

Mother (First)_____________________________ (Last) _________________________________________

Work Place ____________________________________ Phone ___________________________________

Another Person to notify in emergency ________________________________ Phone _________________

Doctor to notify in emergency _______________________________________ Phone _________________

Do you have a sibling playing soccer? Yes No

Sibling’s Name ________________________

Age Group ____________________________

Would either parent be interested in coaching? Yes No

I would like to volunteer to: (please circle)

As needed Team Parent Commissioner Asst.Coach Bd. Member Team Sponsor Fund Raising Registration Field Mt.

List any medical problems _________________________________________________________________

CONSENT FOR MEDICAL TEATMENT

As the parent or legal guardian of the above named player, I hereby give my consent for emergency medical 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.

WAIVER OF LIABILITY

In consideration of the athletic opportunities provided by the Club I do hereby release or otherwise indemnify Hamilton Heights Youth Soccer Club of Cicero, Indiana, its affiliated organizations all sponsors whether of the Club or Affiliated organizations, their employees and associated personnel, including the owners of the fields and facilities utilized for Hamilton Heights Youth Soccer Club programs, against any and all claims by or behalf of the registrant, his estate or any other party claiming on his behalf as a result of the registrant’s participation in the Hamilton Heights Youth Soccer Club Programs and/or being transported to and from such programs or related activities. The undersigned, as parent or legal guardian acknowledges that in any athletic endeavor and upon a proper review of the program outlined by the Hamilton Heights Youth Soccer Club, serious injuries can and may result. It is the expressed intent of the undersigned to release and forever waiver the Hamilton Heights Youth Soccer Club from any and all liability arising from said injuries.

I the undersigned as parent or guardian of the registrant do hereby give my consent to the registrant’s participation and programs and activities of the Hamilton Heights Youth Soccer Club.

PARENT OR LEGAL GUARDIAN:

Signed____________________________ Print Name__________________________ Date_____________