Ridley United Soccer Registration Form printable pdf download

Club Use Only:

Date Received _____________________

Payment Information on Sibling’s Form

Initial ________________

Amount Received $ __________________

Cash

Check (Bank ______________________________ Check # _________________ )

Items Paid: _________ # Travel

________ # Intramural

_______ # Jerseys

Fall Fundraiser

Balance Due $ ______________

Ridley United Soccer Registration Form

Return completed form with payment made payable to Ridley United Soccer to the Ridley United Club House,

Catania Park (formerly Boeing Field) Chester Pike & McCoach St., Ridley Park, 19078

(Behind Ridley Park Police Station) on specified registration dates or mail to PO Box 343, Folsom, PA 19033

Please print all information

Player Status:

Season:

Program:

New

Fall

Intramural

Travel

Returning

New Contact Info?

Yes

Spring

TOPS (Special Needs)

Player Information

Last Name: ________________________________________

First Name: ______________________________ Middle Int.: ______

Address: _________________________________________________________ City: _____________________________________

State: _________________

Zip: ___________________________________

Phone: __________________________________

Father’s Name: _____________________________________

Mother’s Name: _________________________________________

: _____________________________________

Sex:

F Date of Birth: ________________________

E-mail Address

Medical History

List any medical information required to participate in an athletic program:_________________________________________________

Allergies: __________________________________________

Special Medications: ______________________________________

Special Needs: __________________________________________________________________ ____________________________

Emergency Contact (if you are not present): Name: _________________________________ Phone #: ______________________

Intramural Player’s Soccer Skill Level (If unsure, check Average)

The following will assist the club in establishing player team assignments that create evenly matched teams within an age division.

Beginner

Below Average

Average

Above Average

Number of years played ________________________

Parent/Guardian Volunteer Task Selection (Please Select One)

Coach

Assistant Coach

Family/Picture Day (Fall)

Banquet (Fall)

Field Maintenance

Other __________________

Payment Information

Family discounts apply only to fall season, intramural players:

1st player $___________

____ Additional players @ $__________

_________ + Family Fundraiser (Fall only) = $_______________ (Total)

I need (Qty) _____ Reversible Club Jersey(s) x $20 each = $

Release Statement

Note: The statement should be signed by a legal guardian, for himself; an adult player for himself; coach for himself; administrator for himself.

I, the parent/guardian of the registrant, a minor, or adult restistrant of legal age, agree that I and the registrant will abide by the rules of

EPYSA, Ridley United Soccer Club Inc., and its affiliated organizations and sponsors. Recognizing they possibility of physical injury and/or

death associated with soccer and its related actives and in consideration for the EPYSA, RUSC, accepting the registrant for its soccer

programs and activities (the “Programs”), I hereby release discharge and/or otherwise indemnify the EPYSA, Ridley United Soccer Club Inc.,

the Board of Directors and staff, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of

the fields and facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation

in the programs, and/or being transported to or from the same, which transportation I hereby authorize.

Signature: _______________________________________________________________

Date: _____________________________

Ridley United Soccer Club Inc.

PO Box 343, Folsom, PA 19033

610-586-3663

Affiliated with Eastern Pennsylvania Youth Soccer Association, United States Soccer Federation (USSF) and

Federation Internationale de Football Association (FIFA) RG-6 Apr-09

Ridley United Soccer Registration Form

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