Fall 2014 Soccer Program Registration Form

St. Patrick Athletic Association
Participation Registration Packet
Page 1
Fall 2014 Soccer Program Registration Form
Please submit to the Parish Office by September 1st
Events will be held weekly Saturday mornings at Cactus Park (7202 E Cactus Rd.) from 9am-10:30am
September 20th
through December 13th
(with the exception of November 29th
). Entry fee will include
all instruction and a club t-shirt. You will need to make sure your child has shin guards, shoes(soccer
cleats preferred) and a soccer ball. Kids 5-8 should have a size 3 ball. Kids 9-11 should have a size 4
ball.
Family’s Last Name: House Phone:
Mom’s Name:
Mom’s Phone:
Mom’s email:
Dad’s Name:
Dad’s Phone:
Dad’s Email:
Childs name M/F Birth Day Grade Youth Shirt Size
(xs,s,m,l,xl)
1)
2)
3)
4)
Payment
Entry fee is $25 per child for the season. Please make checks payable to “St. Patrick C.C.”
Family Total: $
Other Information
We are in need of volunteer ministers to assist the program as lead coaches, on-field coaching helpers,
and bathroom chaperones. If you are able to help please indicate how you would like to assist.
Please list any special circumstances our coaches need to be aware of (examples: allergy, chronic
illness, or learning disability)?
Office Use Only: Registration Packet Checklist
__ Registration Form __Photo Release __Medical Release __Code of Conduct __Payment Received
Notes:_______________________________________________________________________________________

Page 2
Photo Release Statement
(Please initial ONLY ONE)
____ I hereby grant permission for my child to be photographed and/or videotaped during SPAA
events. I understand that my child may decline to be photographed and/or videotaped at any time.
I further grant permission for the resulting photographs and/or videotaped footage to be edited, if
necessary, and then published and/or broadcast on social media or parish websites for the purpose of
promoting SPAA at St. Patrick Catholic Community.
______ I hereby decline to grant permission for my child to be photographed and/or videotaped during
SPAA events. I have instructed my child to decline to be photographed and/or videotaped at all times.
I have further instructed my child to notify SPAA ministers that he/she may not be photographed
and/or videotaped under any circumstances.
Legal Guardian’s Name (Please Print):
Relationship to participant(s):
Signature: ______________________________________________________ Date:

Page 3
Code of Conduct
The mission of SPAA is to build community, character and virtue through youth and adult sports in a fun and
faith filled environment. By participating in SPAA events participants agree to uphold this mission and the
values of our Christian faith in both actions and words. Every person is a special creation of our Lord and as such
deserves to be treated with dignity and respect.
By signing this document I agree:
1) To treat everyone I encounter at an SPAA event with love and respect.
2) Not to use foul language, racial or ethnic slurs or the Lords name in vain.
3) Not to engage in any behavior that will endanger the health, safety or well-being of any other participant
(athlete, coach, minister or spectator)
4) Not to engage in unsportsmanlike conduct such as, but not limited to, taunting, put downs, and pouting.
5) When using social media, my posts will conform to all aspects of this code of conduct.
I understand that anyone who fails to conform to this Code of Conduct during any SPAA sanctioned event will be
subject to disciplinary action.
(1) Participant’s Name (Please Print):
(1) Participant’s Signature: _______________________________________________Date:
Parent’s Name (Please Print):
Parent’s Signature: ____________________________________________________Date:
Parent’s Name (Please Print):
Parent’s Signature: ____________________________________________________Date:

Page 4
Permission & Medical Release Form
Family’s Last Name:
Participant(s) Name:
____ By signing this release I/we acknowledge the above named persons are permitted to
participate in all St. Patrick Soccer Club events.
__ _ I/we understand that reasonable precaution will be taken to safeguard the health and safety of
the participant(s) and that the designated emergency contact person will be notified as soon as
possible in case of an emergency. In the event of any sickness or accident, person(s) will not hold St.
Patrick Catholic Community, The Diocese of Phoenix, any volunteer, chaperone, or driver responsible.
I/we authorize and consent that emergency treatment be rendered under the general or specific
supervision and on the advice of any physician, dentist, or surgeon: licensed to practice in the State of
Arizona or any other state. The undersigned understands and agrees that any medical, dental, or
hospital expenses incurred shall be at their own expense. The undersigned understands every effort
will be made to notify the emergency contact in the event that treatment is necessary.
Emergency Contact Info
Primary Emergency Contact Parent(s)/Guardian:
Phone Number(s):
If I/we cannot be reached in the event of an emergency, the following person(s) is/are authorized to
act on my/our behalf:
Name: Phone:
Relationship to Participant:
Parent(s)/Guardian(s) Signatures: _________________________________________ Date: _______
Insurance Carrier: Group Id #:
Have all participants received a tetanus shot in the past 10 years? (yes/no)
Do you give permission for Tylenol to be dispensed if requested by minor? (yes/no)
Please list any allergies, health problems or current medications:

Fall 2014 Soccer Program Registration Form

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Fall 2014 Soccer Program Registration Form