Alliance Community Soccer Club Registration Form

(Please complete and sign one page for each player) 

Child’s Last Name:   ___________________________ First: ____________________________ Middle Initial: ________

Address: _________________________________________ City: _______________________ Zip: _________________

Phone: ________________________    Sex:  M  or   F    Date of Birth:_____________  Age at Aug. 1^st 2006 __________

Years Child’s Played ACSC/Recreational:                               Years Child’s Played Competitive:

School Attends:_________________________________

Father’s name: _______________________________                 Mother’s name: ________________________________

Phone: _________________________ Home or Work                 Phone: ___________________________ Home or Work

Phone: _________________________  Cell                                  Phone:  __________________________ Cell

PARENT-Please check any activities you might be interested in:

Head Coach: _________       Assistant Coach: _________      Team Mom/Dad__________       Refereeing: _________   

Please note, ACSC cannot guarantee the placement of a player onto; a specific team, with a requested             teammate, coach or school. Coach and assistant coach’s children will remain the only ones guaranteed.

Alliance Community Soccer Club, Inc.

In consideration of my child participating in the Alliance Community Soccer Club I hereby agree to hold the club, or any of it’s directors, agents, officers, employees, or coaches harmless for any damage to any person or property due to the condition of the facilities which may now exist or subsequently occur and harmless from all claims, actions, damages and liabilities. In the event reasonable attempts to contact me at the phone number(s) listed above have been unsuccessful, I hereby give my consent for emergency medical treatment at the nearest emergency medical facility.

Medical History including allergies, meds, or other: _____________________________________________________

____________________________________________________________________(use back if more room needed)

Signature of Parent or Guardian: _____________________________________________ Date: _____________________

***Make check payable to ‘ACSC’ and Mail to: PO Box 3024, Alliance, Ohio 44601 ***

                                                                                                                                                Total = ___________