Player Development Academy Registration Form

Please fill out the form below and press Register at the bottom. Fields marked with an asterik (*) are required. For additional information, please visit the Player Development Academy.

Player Information *Select One: New or Returning Player

New Players need to give a copy of their birth certificate to John Gotschall.

*Do you need a uniform? (2009 uniforms are okay to use)

*Shirt Size: Select size of shirt *Sock Size: Select size of socks

*Age Chart: Select Age Chart *Gender: Select Gender *First name: Enter the player's first name M.I.: Enter the player's middle initial *Last name: Enter the player's last name *Street Address: Enter house number and street name *City: Enter City's name State: State already entered *Zip Code: Enter Zip Code *Home Phone Number: (Example: 555-555-5555) *Player Email: Enter Email address of player *Date of Birth: (mm/dd/yyyy) (08/10/1995) School Attending: Enter name of school player is attending Mothers Date of Birth: For registration purposes only (month/day)

Father Information Father First Name: Enter father's first name
Father Last Name: Enter father's last name
*Father Cell #: (Example: 555-555-5555)
Father Work #: (Example: 555-555-5555)
Father Email: Enter father's email address

Mother Information Mother First Name: Enter mother's first name
Mother Last Name: Enter mother's last name
Mother Cell #: (Example: 555-555-5555)
Mother Work #: (Example: 555-555-5555)
Mother Email: Enter mother's email address

Emergency Information Alternate Contact: Enter a different contact person Home Phone:(Example: 555-555-5555)
Alternate Phone Number:(Example: 555-555-5555) Doctor:Enter Doctor's name
Business Phone:(Example: 555-555-5555)
Insurance Carrier and I.D. #:Enter Carrier Name and ID number
Allergies, Known Conditions, Medical Problems:

Parent and Player Commitment, Consent and Release:

I hereby give my consent for my child to participate in the Fort Wayne Sport Club (FWSC) Soccer programs. All personnel including the FWSC Youth Soccer Board, coaches, managers, referees, volunteers, other club associations and leagues associated with these programs shall not be held liable for any injury whatsoever my child may sustain in any soccer related activities. I agree to abide by the FWSC policies, procedures and Code of Conduct. I hereby give my consent, in the case of injury, to have an athletic trainer, medical doctor, nurse, hospital or clinic to provide the player with assistance or treatment.

*I am registering for the following Season(s).

Fall Player Development
Winter Player Development
Spring Player Development

By signing and initialing below, you agree to the terms above.

*Parent Name: (necessary if under 18) *Intials: Enter Parent Initials *Player Name: Entry Player name *Intials: Enter Player Initials *Today's Date:(month/day/year) (08/10/1995)