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Taughannock Soccer Club Membership Application Team Level (circle one)
U6 U8 U10 U12 U14
U16 U19 Name: Last: ________________________________First:_______________________________ Address_______________________________________________________________________ Phone _________________________ Email address___________________________________ Birth date (mm/dd/yy): __________ Gender: M F School grade: ____ Years soccer: ____ Father: ________________________ Work phone: _____________ Mother: _______________________ Work phone: _____________ Would you help? Coach__ Assistant Coach ___ Manage __ Fundraise ___ Field Maintenance___ Emergency Contact Name (other than parent): ____________________ Home phone: __________ Relationship: _____________________________________________ Work phone: ___________ Physician: ___________________________________________ Phone: __________________ List any allergies or medical conditions: _______________________________________________ I,
the legal guardian of the applicant (“player”), recognizing the
possibility of physical injury associated with soccer and in
consideration for the Taughannock Soccer Club (TSC) accepting the
applicant into its soccer programs and activities, hereby release,
discharge, and/or otherwise indemnify the TSC, its affiliate
organizations and sponsors, their employees and association
personnel, including the owners of fields and facilities used for
TSC programs, against any claim by or on behalf of the applicant as
a result of the applicant’s participation in TSC programs and/or
being transported to or from the same, which transportation I hereby
authorize. The above applicant and I hereby give consent for
emergency medical care prescribed by a duly licensed Doctor of
Medicine or Doctor of Dentistry. This care may be given under
whatever conditions are necessary to preserve life, limb, or well
being of my dependent. I accept responsibility for payment of any
such services provided. Signature of Parent/Guardian _________________ Date : _________________ Annual membership fee ($25) ______ (Program fees are additional and vary with the program.) Make checks payable to
Taughannock Soccer Club, Inc. |