Warren United Soccer Club Registration Form

U11 Boys Highlanders

Player Information                           Sex  M   F (Choose One)                   Birth Date  (MM/DD/YYYY)

First      Middle Init.             Last   

Address             

City            State             Zip

Main Phone # (555 555-5555)

Uniform Size (Click one for each)

Shirt YM  YL  AS  AM  AL  AXL    Parents email

Short YM  YL  AS  AM  AL  AXL Players email (Optional)

Check the Position or Positions Desired (Click All That Apply)

Goalie         Defender          Midfielder       Forward 

(The coach will determine final positions)

Will you be playing another sport in the Fall/Spring? No   Yes   

What Sport? 

Medical Concerns (Please any medical conditions that the coach should be aware of)

Parental Information        

Fathers First Name Fathers Last  Name

                Home Phone           Cell Phone

Mothers First Name  Mothers Last Name

                Home Phone         Cell Phone

Please help support our club. Please check something you are willing to help with. (Coaches can answer any Questions)

Parent Representative     SAGE Rep Sideline Flag

Do you have a coaching license? YES    NO   

Are you willing to coach or assist? YES NO

If yes what level?  F   E   D  C B  A

Name of person with license?  

How did you hear about these tryouts? 

School Flier     Word of mouth    Newspaper Roadside Sign     Movie Theater    Channel 21  

Online Web Search     Attended A Warren United game    Poster in Store     Already on Team   Other  

We occasionally have the opportunity to post pictures on our web site or in the local newspapers. We need your permission to do this. Please check the only one box below which reflects your thoughts the best. For more information on this please click here

                I/ We GRANT permission for my child’s photo/image and name to be published on the Club’s Internet site as well as in local newspapers.

              I/ We GRANT permission for a photo/image that includes my child’s image without name to be published on the Club’s Internet site as well as in local newspapers.

              I/ We DO NOT GRANT permission for a photo/image that includes my child’s image without name to be published on the Club’s Internet site as well as in local newspapers.

  RELEASE This release is made to allow my/our child to participate in the Warren United Soccer Club Team Tryouts and recognize that my/our signature on this release is a condition of our permitting my/our child to participate. I/We certify that my/our child is in excellent physical health, there are no physical limitations to my/our child to participate in this program, may participate in strenuous and hazardous physical activities, and grant permission for my/our child to receive emergency medical treatment if needed. I/We herby release and discharge Warren United Soccer Club, Washington Twp. Washington Boro, Mansfield Twp, Franklin Twp., White Twp., club evaluators, volunteers, coaches, and all their affiliated entities from any and all liability, claims, demands, and causes of action for personal injury, property damage and/or other loss suffered by my/our child in connection with his/her participation in this program. I/WE represent that I am/We are the parents/guardians of the minor named above, and I/We agree that the grant and releases contained therein binds me/us and the minor to all of its terms.

 Parent Name (Please Fill in Parent Name only if you agree to the release above. (Failing to sign below will result in your child not participating in Warren United Tryouts)

Parent/Guardian Agree         Date