Breakers Registration

2015 WLYSC BREAKERS Soccer REGISTRATION FORM

COST IS $100 for Fall and $100 for Spring (plus uniform fee)

PLEASE FILL OUT THE FORM COMPLETELY
ONE FORM FOR EACH PLAYER (YOU MAY PAY TOGETHER)
HIT THE SUBMIT BUTTON WHEN DONE
YOU WILL BE DIRECTED TO A NEW PAGE FOR PAYMENT

* Indicates required field

Player Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth (mm/dd/yyyy) *

Grade (Fall of 2015) *

School *

Shirt Size (please choose) *

Special Considerations (i.e. unavailable practice nights) *

Parent/Guardian Information *

First

Last

Contact Phone Number *

Alternate Number *

Email *

Parent/Guardian Information 2 *

First

Last

Contact Phone Number 2 *

Alternate Number 2 *

Email *

Health Concerns (i.e. asthma, injuries) *

PHOTO RELEASE
WE OCCASIONALLY MAY USE PHOTOGRAPHS OF THE PLAYERS FOR MARKETING MATERIALS OR ON THE WEBSITE, PLEASE CHOOSE "YES" IF YOU APPROVE. THANK YOU.

Choose One (photo release) *

YES NO

PARENT & ATHLETE CONCUSSION INFORMATION SHEET (mandatory)
Please print out the concussion form HERE, sign (both parents/guardians and players) and return on the first night of practice. One for each player, not household.

Code of Conduct Form (mandatory)
Click HERE for the Code of Conduct Form
Please read these rules with your child and make sure you both understand them and agree to follow them. Any violation of these rules will be subject to some form of disciplinary action appropriate to the infractions, up to and including suspension. Any suspension would be subject to approval of the Board of Directors, after meeting with the parents.

Signature (code of conduct) *

Agree

RELEASE, INDEMNIFICATION AND HOLD HARMLESS AGREEMENT (MANDATORY)
CLICK HERE FOR FORM. ONCE READ COMPLETELY, CLICK AGREE BELOW.

BY CLICKING "AGREE" BELOW, I HAVE READ THE ABOVE DOCUMENT AND I HEREBY GRANT MY CHILD PERMISSION TO PARTICIPATE IN THE WHITE LAKE YOUTH SPORTS CLUB PROGRAM. I UNDERSTAND THAT BASKETBALL IS A FULL CONTACT SPORT AND THAT PARTICIPATION IN A CONTACT SPORT INCREASES MY CHILD’S PHYSICAL VULNERABILITY. I ALSO AGREE TO PROVIDE MY CHILD WITH QUALITY PROTECTIVE EQUIPMENT. I HEREBY CERTIFY THAT THE INFORMATION ON THIS FORM IS TRUE AND ACCURATE AND I HAVE READ THE ABOVE FILE COMPLETELY.

Signature (liability release) *

Agree

Payment Options (choose one) *

Pay in Person Pay Online

Submit

﻿2015 WLYSC BREAKERS Soccer REGISTRATION FORM ﻿

2015 WLYSC BREAKERS Soccer REGISTRATION FORM