P.O. Box 2067
Port Washington, New York 11050
516-767-3944
INTERTOWN@PWSOCCER.COM
Fall 2012 Intertown Application
The Port Washington Soccer Club is a Community Chest sponsored organization, run by volunteers to provide a soccer program to approximately 900 youth of our community. The Soccer Club retains professionals to train and assist coaching the children. If you are interested in coaching or helping in other areas, such as scheduling referees, picture taking
public relations, trophy distribution, the annual picnic, or fundraising, please let us know. Your help would be sincerely appreciated.
PLEASE READ AND COMPLETE REVERSE SIDE.
Fall 2012 Early Registration must be postmarked by August 31th
Registration Ends September 8th
Application
Player’s Name______________________________________________Male/Female ______________________
Birth Date_____________________School_______________________________________Grade________________
Parents Names____________________________________________________________________________________
Street Address________________________________________________Email____________________________
Phone_________________________ Parent willing to coach?(yes/no)_______Volunteer?(yes/no)______
Alternate Emergency Contact________________________________________Phone________________________
_______________________________________________________________________________________________
PARENTAL PERMISSION
Port Washington Soccer Club, Inc. provides supervised soccer and related activities for children. I, the parent or legal guardian of the above named applicant, hereby give my permission and approval for his/her participation in the activities indicated. I assume all the risk and hazards incidental to the conduct of activities and hereby release indemnify and hold harmless, the Port Washington Soccer Club, Inc., its Officers, Directors, Coaches, Members, Consultants, Supervisors, Managers, and employees, any and all of them, and likewise release from responsibility any person transporting the applicant to or from any activity scheduled or arranged by the Port Washington Soccer Club, Inc.
I consent to any emergency medical treatment of the applicant and hereby assume responsibility for payment for any such treatment.
Parent’s Signature____________________________________________________Date_______________________
