PLEASURE  ISLAND  SOCCER  ASSOCIATION

Spring 2012 Academy Registration

PLAYER NAME:     First:  Last:

 MALE FEMALE   Birth date: //   On Aug. 1, 2011, I was: yrs old. 

 ADDRESS: (City) (zip)

 Parent/Guardian: First:  Last:

 Phone #'s: Cell #1:--  Cell #2:-- Work:--

 Best EMAIL address: @ .

   2nd EMAIL address: @ .

Jersey Size:   Youth:   X-Small     YS    YM     YL    Adult:  Small      AM      AL       AXL

 Waiver of Liability: We/ I, as the parent/legal guardian of the player named above, do hereby declare our intent to allow this child to practice, play, and participate in all programs and activities associated with the Pleasure Island Soccer Association, including any related activities and transportation. We/ I hereby release and hold harmless from any and all liability; Pleasure Island Soccer Association, its coaches, sponsors, associated board members and personnel, officials, or any others associated with this organization against any claim by or on behalf of the player’s participation in this program.

Medical Consent Release: We/ I do hereby authorize Pleasure Island Soccer Association or any representatives including coaches, officials, or anyone associated with this organization, if after reasonable attempt has been made to reach the designated parent/guardian named above to consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment or hospital care, to be rendered to the player under the general or special supervision and on the advise of any physician, dentist or surgeon duly licensed to practice, be indeed rendered to the Registrant

 1. FORM MUST BE NOTORIZED BELOW (if you did not notarize Fall 2011)

 2. INCLUDE A COPY OF BIRTH CERTIFICATE (if you did not send Fall 2011)

 3. Include check/money order for $120 (add $15 for custom soccer ball). Send to "PISA Academy" PO Box 1868, Carolina Beach NC 28428

 4. You may also pay online, or bring form to the registration at the field. 

X___________________________________________           X__________________________________________________               

 Parent/ legal guardian (Print Name)                                                                                         (Sign Name)                                  

Subscribed and sworn to (or affirmed) before me on this the ______day of ____________2012

 _____________________________________               County of:         New Hanover          State of:     NC               

                        Notary Public Signature                                         My Commission Expires: ____/_____/_______.                    (  SEAL  )