2012 Spring REGISTRATION at Panola County Armory, 333 S. Market Street
Thursday 2-16-12 6:00pm to 8:00pm / Saturday 2-18-12 10:00am to 12:00 noon
Febuary 18, 2012 (this will be last date available)
Pay with Check or Money Order made out to CSA
Amount Paid:__________
Please include DL # ___________ (info after 5pm: DOUG 903-754-2547 or 903-754-9607)
Payment Method:_____Received by___
Spring 2012 Registration Form
The registration fee is $60.00 first child and each additional brother/sister fee being $55.00 per child Shin guards will not be provided, but will be mandatory for game play and practices. All players must be a minimum of four (4) years as of 7/31/2011.
If Child played the 2011 FALL; Team Name________________________ Coach_______________________ registration fee is $30.00 first child and each additional brother/sister fee being $25.00 per child if played in Fall 2011
CHILD’S NAME:_____________________________________________________ DIVISION:_______
BIRTH DATE:____________________________ SEX: (circle one) Male Female
AGE AS OF 7/31/2011_______
PARENT’S NAME __________________________________, ______________________________________
HOME PHONE:________________________________ Cell ___________________________________
HOME MAILING ADDRESS:____________________________________________________________
ALTERNATIVE #:________________E-MAIL ADDRESS:______________________________________________
PHYSICIAN: DOES YOUR CHILD HAVE ANY MEDICAL CONDITIONS AND OR ALLERGIES WHICH YOUR CHILD’S COACH SHOULD BE AWARE OF? IF SO, PLEASE LIST AND EXPLAIN use back side if needed____________________________ ________________________________________________________________________________________________
UNIFORM SIZE (Circle one Shirt / Circle one Shorts)
YOUTH or ADULT
SHIRT size S M L ---------- S M L XL
SHORTS size S M L --------- S M L XL
I, the parent /guardian of the registrant, a minor, agree that I and the registrant will abide by the rules and regulations of the Carthage Soccer Association (CSA), its affiliated organizations and sponsors. Recognizing that there is a possibility of injury associated with soccer and in consideration for CSA accepting the registrant for its soccer program and activities (the “Program”), I do hereby hold CSA and the owners of fields and facilities utilized for the Program harmless against liability for loss or injury sustained while participating in the Program and do further indemnify them against any potential claims accordingly.
Parent/Guardian Signature___________________________________ Date:____________________
I would like to actively participate in CSA (Coach, Team Mom, etc.) Yes No
Carthage Soccer Association, P O Box 132, Carthage Texas, 75633 MUST HAVE COPY OF BIRTH CERTIFICATE! If not on file