2012 PLAYER REGISTRATION FORM

MAIL TO: Helen Tupper 10986 Stampville Road, R.R. #2 Iroquois, Ontario K0E 1K0 All cheques made payable to: South Dundas Soccer Association

REGISTRATION FEE IS $40.00

RETURN BY: MARCH 25, 2012 or a LATE FEE: $20.OO per child will be charged
PLAYER INFORMATION: FIRST NAME LAST NAME DATE OF BIRTH dd/mm/yy(must be born between 1994-2007) SEX

NAME OF SCHOOL PLAYER ATTENDS

CIRCLE SHIRT SIZE

Youth 6/8(YSm) 10/12(YMed.) 14/16(YLrg.) Adult Sm (IF IN DOUBT SELECT NEXT SIZE UP) Med Lg Xlg

IS PLAYER INTERESTED IN PLAYING GOALIE

(Please circle one)

YES NO PLEASE DESCRIBE ANY MEDICAL PROBLEMS THAT WE SHOULD BE AWARE OF:

HAS THE CHILD PLAYED FOR THE KICKERS TRAVELLING TEAM IN THE LAST 2 YEARS. (Please circle one) YES NO

KINDLY NOTE THAT EVERY REASONABLE ATTEMPT WILL BE MADE TO ENSURE YOUR CHILD IS PLACED WITH PLAYERS FROM THE SAME SCHOOL OR A FRIEND AT THE LITTLE SQUIRT, JUNIOR, INTERMEDIATE AND SENIOR DIVISIONS (2000-2007), THIS WILL NOT BE DONE AT THE BANTAM AND MIDGET DIVISIONS DUE TO SKILL LEVEL, NUMBERS AND TIME.

PARENT OR GUARDIAN INFORMATION:

FIRST NAME LAST NAME ADDRESS: PHONE NO. E-MAIL ADDRESS

VOLUNTEER INFORMATION:
FIRST NAME LAST NAME PHONE #

WHICH OF THE FOLLOWING ARE YOU AVAILABLE TO ASSIST WITH? PLEASE CIRCLE. Coaching Refereeing Canteen

COACHES PLEASE CIRCLE YOUR SHIRT SIZE. ADULT Sm Med Large Xlg XXlg

Tournament Committee Member

PHOTOGRAPHY & WAIVER OF LIABILITY:

I realize there is potential risk of injury from the activities involved in this program. I knowingly and freely assume all such risks, both know and unknown. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the South Dundas Soccer Association, their officers, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (Releasees), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, WHETHER CAUSED BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. As parent/guardian with legal responsibility for this participant, I hereby consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify the Releasees from any and all liabilities incident to my childs involvement or participation in the program as provided above. I hereby permit the use of my childs team picture or candid sports shot on the South Dundas Soccer Associations website and/or other promotional material. All other use of my childs picture is prohibited.

PARENT/GUARDIAN SIGNATURE X _________________________ DATE SIGNED: