Mail to: DHD Soccer Summer School
42 Spring Street, Suite 40 Newport, RI 02840
Registration Form
Player’s Name: ________________________________ Date of
Birth: _______________
Address:
______________________________ City: ________________ Zip:
__________
Please check appropriate session:
Monday: ____ Under 8 - Fundamentals 101 ____ Under 10 -
Fundamentals 101
Tuesday: ____ HS - Tactics and Decision Making ____ HS -
Goalkeeping 301
Wednesday: ____ Under 12 - Fundamentals 101 ____ Under 14 -
Fundamentals 101
Thursday: ____ Under 12 - Fundamentals 201 ____ Under 14 -
Fundamentals 201
____ Under 12 & 14 - Goalkeeping 101 ____ HS - Fitness
& Conditioning
T-shirt size: ___ YM ___ YL ___ S ___ M ___ L ___ XL
Emergency Information
Parent/Guardian #1: ______________________________
Home Phone: _______________ Cell Phone: _______________
Parent/Guardian #2: ______________________________
Home Phone: _______________ Cell Phone: _______________
Family Physician’s Name: ______________________________
Phone: _______________
Medical Insurance Carrier:
____________________________________________
Policy Holder Name: ____________________ Group Plan Number:
________________________
1. List any allergies or allergic reactions
_________________________________________
2. Taking any medication at this time
__________________________________________
3. List any special needs
_____________________________________________________
DHD
Soccer Release Statement
I agree to the
unreserved use of my child’s name and/or likeness
(including photographs, videotapes, and other depictions)
for publication. In consideration of the acceptance of this
application for entry into the Summer School, I hereby
waive, release and discharge any and all claims for
damages, for death, personal injury, or property damage
which my child may have, or which may hereafter accrue to
him/her as a result of my participation in the DHD Soccer
Summer School. This release is intended to discharge DHD
Soccer, the Town of Middletown and Middletown Youth Soccer
Club, their officers, agents and employees, organizers,
officials and staff and other participants or spectators
from and against any and all liability arising out of or
connected with my child’s participation in the DHD Soccer
Summer School.
I am aware that this activity subjects my child to physical
risks and dangers. Nevertheless, I voluntarily agree to
assume any and all risks or injuries or death, and to
release, discharge and hold harmless all of the entities or
persons mentioned above. It is understood and agreed that
this waiver, release and assumption of risk is to be
binding on by heirs, personal representatives, next of kin,
spouse and assigns.
Parent/Guardian
Signature: ______________________________ Date:
_______________
Tuition:
___ $125.00 before 01 June 2008 ___ $140.00 after 01 June
2008