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Pompton Lakes Riverdale Soccer Association

 

PLRSA Player Registration Form

Player Information (*=required)
First Name: *
Last Name: *
Grade in Fall: *
Address 1: *
Address 2:
City:*
State:*
Post/Zip Code: *
Birthdate:*
mm/dd/yyyy
Home Phone :*
i.e. 555-555-5555
Cell Phone: (if applicable)
Email:* (primary)
Gender:*
   

Parent/Guardian Information (fill in all that apply)
Parent #1 (where the player resides)
  First Name:*
Last Name:*
Relationship:*
I wish to Volunteer



Volunteer Position*
Work Phone
Cell Phone:
Email:
(may be same as above)
Parent #2 First Name:
Last Name:
Relationship
I wish to Volunteer



Volunteer Position
Work Phone
Cell Phone
Email:
Please fill in the below if different from Player
Home Phone
  Address1
Address2
City
State:*
Post/Zip Code: *
Emergency Contact Information
Full Name:
Relationship:
Phone
Medical Information
Doctor Name:
Doctor Phone:
Dentist Name:
Dentist Phone:
Hospital Name:
Insurance Company:
Policy Number:
     
Medical
Comments :
Authorization
I, the parent or legal guardian of the player indicated above do certify that this player is fully able to participate in the PLRSA program. I hereby give my consent and agree to release, indemnify and hold harmless the PLRSA, its officers, coaches and other representatives from any claims arising from injury to the above indicated player. Further, in the event of emergency and when I am not available, I do hereby authorize the coaches, assistant coaches, officers, or parents of team members acting in the capacity of activity supervisor, as agents for the undersigned to consent to medical, surgical or dental examination and/or treatment by appropriate medical or dental personnel. Also, I hereby authorize emergency treatment and/or care at any hospital for this player.
Legal authorization and consent for all above items:

- I hereby authorize emergency treatment and/or care
and or/care
if No - a parent or Legal GuardianMUST be present at each game and practice

Submit Your Registration
you will then have a choice of entering more players or paying Online or finish for today and come to a registration to complete payment.
I would like to get a copy of what would be sent to PLRSA (cc_visitor)