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PA West - North United COE Academy

Registration Form

Please provide the following player information:

Please use the TAB key or your MOUSE to move between fields.

 

New Player   Returning Player 

 

First Name

Last Name

Street Address

Address (cont.)

City

State/Province

Zip/Postal Code

Home Phone

-

 

 Age:    Birthdate:            Grade:   Gender:   

       / /              

 

Enter the best E-mail address for the club to use when contacting you. Be sure to put an address that you have access to on the weekends.

 

Please re-enter your email address above to verify it.

 

Please provide the following information about the player's Father:

Name

Occupation

E-Mail

Cell Phone 

-

Work Phone

-

 

Please provide the following contact information about the player's Mother:

Name

Occupation

E-Mail

Cell Phone 

-

Work Phone

-

 

Enter your School in the space provided below.

    

 

Enter your Municipality in the space provided below.

 

Enter your Soccer Club in the space provided below.

 

What day will your home club games be? 

 

Medical Information

 

Do you have any medical conditions or needs?

 

How did you hear about North United? 

 

Fee Information:

 

Returning players from the fall or Winter session the fee is $135.00 for the 8 sessions. New to the program players the fee is $150.00 and includes your COE registration and two tee shirts.  New players please select your shirt size.

 

 　 　

Spring Season Fee:    

$150.00   Players not in the fall or Winter session

$135.00   Returning players.

 

First session will be Saturday, September 6 2008. 

 

Money is due 7 days after registration to hold your spot.

 

Please mail all payments to:  NUCS   PO Box 737    Ingomar, PA 15127.

 
 Consent and Waiver Information:  

 

Consent

The applicant has been granted permission to attend and participate in the USYSA/PA West District Center of Excellence.   In exchange for the privilege of participation, I, parent/guardian of the above applicant, a minor, agree that I and the participant will abide by the rules of the USYSA/PA West, their affiliated organizations and sponsors.  Recognizing that the possibility of physical injury association with soccer, I hereby release, discharge and/or otherwise indemnify the USYSA/PA West, North United Classic Soccer Club  and their affiliates, their employees and associated personnel, including owners of fields and facilities utilized for PA West and District Centers of Excellence against any claims by or on behalf of the registrant as a result of participation. 

As the parent or legal guardian of the above player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry.  I agree to be responsible financially for the reasonable cost of such assistance and/or treatment.  

I agree to my child receiving medication as instructed and any emergency dental, medical or surgical treatment, including anesthetic or blood transfusions, as considered necessary by the medical authorities present. 

I agree to inform the Technical Director of the District Center of Excellence if there are any changes in my child’s health before the activity.   

This release shall remain in effect for the durations of the seasonal year and shall be interpreted under Pennsylvania Law.

I (enter your name here)  have read, understand, and agree to all the terms stated above as they relate to (enter player's name here) and the Center of Excellence.  

Date of agreement:  / / .