Jasper Indoor Soccer

 

Mail Registration & Check to:

Jasper Skate Palace

1013 4th Ave  Jasper, IN  47546

 

October 2007 Registration Form

 

Player’s Name________________________________

 

Parent/Guardian Name(s):_________________________

 

Address:__________________________  Zip:___________

 

Phone Number(s):___________________________

 

Age:______   Sex: _____   Birth (M/D/Y):_______________

 

Grade Currently in:_________  School:________________

 

Highest Level of Play:  Rec.  Travel   H.S   Other:_______

 

Any Medical Conditions?________________________

 

T-Shirt Sz:  6/8  10/12  14/16  AS  AM  AL  Other:____

 

Will you help run the team during game play?  Y   N

 

Up to Grade 2:  $40.00         Grade 3 and up:  $50.00

 

Signed by Manager:___________________________Date:_______________

 

Waiver (Must Be Signed):  _______________________

I/We waive any and all rights and claims against the Jasper Skate Palace its board of directors and or staff arising in or out of participation in the Sports Palace Soccer Program.  I/We do further agree to hold the above names blameless for any liability whatever arising from injuries suffered by the person registered above while a participant in the program.