Jeffersonville Soccer Evaluations - 2020
Email address *
Player's First Name *
Your answer
Player's Last Name *
Your answer
Street *
Your answer
City *
Your answer
State *
Birth Date *
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DD
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YYYY
Gender *
Parent 1 Name (First and Last) *
Your answer
Parent 1 Email Address *
Your answer
Parent 1 Phone Number *
Your answer
Parent 2 Name (First and Last)
Your answer
Parent 2 Email Address
Your answer
Parent 2 Phone Number
Your answer
While attending each session is recommended, which sessions will your player be attending? (Check all that apply) *
Required
Name of Soccer Club your child played for last year. *
Your answer
Name of School *
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Name of School District *
Your answer
Additional comments or questions:
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Release Statement
I, the parent/guardian of registrant, a minor, agree that I and the registrant will abide by the rules of Eastern Pennsylvania Youth Soccer, and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for Jeffersonville Soccer Club accepting the registrant for its soccer programs and activities ("the Program"), I hereby release, discharge and/or otherwise indemnify Eastern Pennsylvania Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of registrant's participation in the Programs, and/or being transported to or from the same which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer and/or doctor of medicine or dentistry provide my child with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of each assistance and/or treatment. *
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