Rec Registration

PLEASURE ISLAND SOCCER ASSOCIATION

- Spring 2012 RECREATION LEAGUE Registration -

PLAYER NAME: First: Last:

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

ADDRESS: (City) (zip)

Parent/Guardian: First: Last:

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

Best EMAIL address: @ .

2nd EMAIL address: @ .

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

If possible I want to be on the same team as Fall 2011. NA, Y, N Team or Coach Name:

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

X:_________________________________________ X:_________________________________ //

(Parent/Guardian - Print Name) (Sign) (date)

Age on 8/1/11	Born Between	By Jan. 21	Coach & Military	Sponsor Child	After Jan. 21	$5 discount for
3	08/1/2007 - 12/31/2008	$45.00	$25.00	FREE	$55.00	each additional
4	08/1/2006 - 07/31/2007	$45.00	$25.00	FREE	$55.00	brother & sister
5	08/1/2005 - 07/31/2006	$55.00	$35.00	FREE	$65.00
6	08/1/2004 - 07/31/2005	$75.00	$55.00	FREE	$85.00	One $20 coach's
7	08/1/2003 - 07/31/2004	$75.00	$55.00	FREE	$85.00	discount per team
8	08/1/2002 - 07/31/2003	$80.00	$60.00	FREE	$90.00
9	08/1/2001 - 07/31/2002	$80.00	$60.00	FREE	$90.00	Add $10 late fee
10	08/1/2000 - 07/31/2001	$80.00	$60.00	FREE	$90.00	after Jan.21
11	08/1/1999 - 07/31/2000	$80.00	$60.00	FREE	$90.00
*12-13	08/1/1997 - 07/31/1999	$80.00	$60.00	FREE	$90.00	Money Order or
*14-17	08/1/1993 - 07/31/1997	$80.00	$60.00	FREE	$90.00	Check to "PISA"

Mail check/money order payable to “PISA”, PO Box 1868, Carolina Beach, NC 28428 by Jan. 21. If post-marked after Jan.21, $10 late fee will apply. Applications received after Jan. 31 will be added to wait list

*I want to COACH my child’s team: Y or N ($20 refund if approved). Cell #: --.

*I want to SPONSOR team: Y or N (tax-deductible) and waive one child's registration fee. Cell #:--

SPONSOR FEES: Age 3 & 4 = $200, All other $250. Pays for uniforms, name on jerseys and ad on website for the season.

BUSINESS NAME: Contact:

WEB ADDRESS: www. .

Simply include the sponsorship fee with completed registration form and mail to the PO Box 1868, Carolina Beach, NC 28428.