Soccer Registration 2018-19

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REGISTRATION DEADLINE: August 15, 2018

FEE (your tuition account will be billed):
Kindergarten (on or before August 15, 2018): $90
Kindergarten (after August 15, 2018): $120

Grades 1-2 (on or before August 15, 2018): $100
Grades 1-2 (after August 15, 2018): $130

Grades 3-8 (on or before August 15, 2018): $110
Grades 3-8 (after August 15, 2018): $140

Student First Name *

Student Last Name *

Date of Birth *

YYYY

Gender *

Grade *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email *

Phone *

xxx-xxx-xxxx

Address *

City *

Zip Code *

Emergency Contact Name *

Emergency Contact Phone *

Doctor Name *

Doctor Phone *

Preferred Hospital *

Insurance *

Policy # *

Special Circumstances/Medical Information

My MIDDLE SCHOOL student has permission to walk home after practice.

CYO Information

Catholic? *

Parish

Ethnicity *

Asian

Black or African American

Middle Eastern

Multi Racial

Native American

Other

Pacific Islander

White

Prefer not to answer

Required

Hispanic? *

Parent Authorization

MEDICAL RELEASE *

I, the parent/guardian of the above named student authorize that my child be given emergency treatment to include first aid and CPR by a qualified staff member. In addition, I authorize and consent to medical, surgical, and hospital care treatment and procedures to be performed for my child by his/her regular physician (or when that physician cannot be reached, by a licensed physician or hospital) when deemed immediately necessary or advisable by the physician, to safeguard my child's health, when I cannot be reached. I also give permission for my child to be transported by ambulance or aid car to an emergency center for treatment. I waive my right to consent to such treatment and /or transportation and agree to pay the cost of such emergency care and/or transportation. I release and agree to hold Villa Academy, its agents, employees, officers, coaches, leaders, organizers, and sponsors harmless for any liability resulting from such emergency treatment and/or transportation.

Required

FEES *

Scholarships are available—contact Angela Dugan - x260

I understand that the CYO Soccer Fee will be billed to my Tuition Account

Required

PARENTAL AUTHORIZATION *

I give permission for my child to participate in any school sponsored competitive athletics. In consideration of the opportunity for my child to participate, and fully recognizing that such an undertaking involves an element of risk, I assume all risks and hazards incidental to such participation and do hereby release, absolve, indemnify and agree to hold harmless the Archdiocese of Seattle, Villa Academy, its agents, employees, officers, coaches, leaders, organizers, sponsors and persons transporting the athlete to and/or from activities. Neither the Archdiocese, Villa Academy, or any of said persons, shall be financially responsible for any injury, illness or death incurred as a direct or indirect result of this activity. I, the undersigned, have read this release and understand all of its terms and execute it voluntarily and with full knowledge of its significance.

Required

Parent Signature *

Date *

YYYY

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