Bedford Soccer Association Registration Form

2004

1394 Bedford Hwy. Bedford, NS. B4A 1E2

Web Site: http://bedfordtitans.com

Email: Registrar@themarketingclinic.ca

 

 

MUST BE RETURNED BY MARCH 1ST, 2004 TO ADDRESS ABOVE

 

Player  Information (please verify all information, and correct if necessary)

 

 

Please circle actual age level:   U6     U8     U10     U12     U14     U16     U18

 

Player’s Name:

Phone:

 

Mailing Address:

 

Town/City:

Postal Code:

 

Date of Birth (MM/DD/YY)

Gender:     M     F

 

Health Card Number:

Expiry date:

 

Please advise of any medical conditions:

 

Last School Attended:

 

Name of ONE friend you would like to play with:

 

Can we use your childs picture(s) on the web site or other forms of media publications?  Yes      No

 

If sibling also plays in Bedford Soccer. Please circle Level U6  U8  U10  U12  U14  U16  U18

 

If you would like to play at a different age level, please indicate desired level:

Please circle one:     U6     U8     U10     U12     U14     U16     U18

Reason: _____________________________________________

 

 

Would you like to try out for a competitive team (U12 to U18 only)    Yes     No

If Yes:  You will be contacted via e-mail or phone with tryout schedule.

If No:  You will be placed on a Tier II B Team & contacted by your coach

 

Parent Information (please verify all information, and correct if necessary)

Mother’s Name:

E-mail:

Day Phone:

Home Phone:

Father’s Name:

E-mail:

Day Phone:

Home Phone:

Physician Name:

Phone:

In Case of Emergency, Notify         

Name:

Phone:

 

Fees

U6   = born in 1998/99          $ 70.00        

U14 = born in 1990/ 91        $110.00

U8   = born in 1996/97          $ 70.00

U16 = born in 1988/ 89        $110.00

U10 = born in 1994/95          $ 80.00

U18 = born in 1986/ 87        $120.00

U12 = born in 1992/93         $100.00

Note: U6 Boys and Girls play on same teams

                                                   FEE =

  $

Family Rate Deduction (deduct $20 per child if there are three or more players):

- $

 

 
Total Payable   =

   $

Make cheque(s) payable to Bedford Soccer Association, and mail to:

1394 Bedford Hwy. Bedford NS. B4A 1E2

Please return by March 1st, 2004

Office Use Only:        Cheque ____   Cash ____     Money Order____  Age Verified_____________  

Verified by ______________________   Date_________________  Note Multiple Children ___________

 

Volunteer  Information

Volunteers are vital to the success of our organization.  Let us know how you will participate.

Name:

Phone:

Level you want to volunteer at. Please circle one:   U6     U8     U10     U12     U14     U16     U18

I can volunteer for: 

Team Manager_____  Coach_____  Assistant Coach_____  Phone Committee_____  Car Pool_____  League Coordinator_____  Executive_____  Fund Raising_____  Social Committee _____Other_____ 

Past Volunteer Experience___________________________________________________________

We will provide you with an important two day Coach/Assistant Coach training. Are you interested in attending?            Yes          No

 

As a Parent/Guardian I understand that soccer is a contact sport and that injuries can occur. I will not hold the Bedford Soccer Association or any of its members, volunteers, or employees responsible for any injury, unless negligence is proven.

__________________________________________________________________________

Signature of Parent or Guardian                                  Print Name                                  Date