Winter Soccer Training Registration

Please fill out the form below and press Register at the bottom. Any questions, contact Cory Rodgers at cory.rodgers@fortwaynesportclub.com

Player Information *Coach: Enter the player's coach name *Age Bracket: Enter the player's age group *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: (month/day/year) (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 clinic(s).

Winter 1 1v1 Clinic ($80) Winter 2 1v1 Clinic ($80) Winter 1 Strikers Clinic ($80) Winter 2 Strikers Clinic ($80) Winter 1 Goalkeeper Clinic ($120) Winter 2 Goalkeeper Clinic ($120)

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

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