4Cheektowaga Soccer Club Registration Form

Please complete all fields on the application

mail it with your registration fee to:

Cheektowaga Soccer Club, P.O. Box 1865, Cheektowaga, NY 14225

Last Name: Age Division: Circle One

First Name: 4-6 Division 6-8 Division

Address: 9-11 Division 9-11 Division

Town/Zip:

Home Phone:

Date of Birth/Age

School:

Grade:

Gender: Male Female

Father’s Name: Cell Phone: Email address:

Mother’s Name: Cell Phone: Email address:

Emergency Contact: Phone: Relationship:

Registering for:

Winter House League $75 plus $25 mandatory fundraising for total of $100

Must be postmarked by Aug. 1, 2015. If postmarked after this date, a $10 late fee will be applied

Uniform Size:

Youth Small Youth Medium Youth Large

Adult Small Adult Medium Adult Large Adult X-Large

Medical considerations:

Insurance coverage:

Would you like to coach or assist a house league team? Yes No

Has this child ever played soccer before? Yes, how many years? No

Has this child ever registered with CSC before? Yes No

What teams/leagues have they been involved with?

Do you have an interest in playing travel soccer?

Yes No Not sure, would like more info.

Do you currently play travel soccer with the Cheektowaga Soccer Club or any other travel team?

Yes No

How did you hear about CSC?

By signing this waiver, I give my permission to the Cheektowaga Soccer Club to use my child’s photograph in publications of the association, which include information and public relations materials. This release is in effect until such time I request in writing that I want to discontinue the use of my child’s photos. I understand that participation in youth soccer presents a risk of injury, and I agree to hold harmless and indemnify the Cheektowaga Soccer Club, its board, officers, coaches and members for and against any and all claims of any nature from my child’s participation in the soccer program. I certify that my child has been declared by a physician to be physically able to participate in the soccer program without any restrictions. A $25 fee will be applied to all returned checks. Furthermore, I agree that my child, myself and all family members, friends, associates, etc. will abide by the CSC Zero Tolerance and Sportsmanship Policy and Refund Policy, which can be viewed on our website at www.cheektowagasoccerclub.com.

Parent or Guardian’s Signature: ______Date: ______

Print Parent or Guardian’s Name: ______Rev. July 2015