Norfolk County Futsal League - Academy Registration Form

Welcome

Futsal Overview

Futsal Rules & Reg's

New England Futsal Academy

League Information

League News

Game Schedules

Register Online!

Photo Gallery

home

mailing address:
Norfolk County Futsal
55 Glendale Street
Tiverton, RI 02878

Norfolk County Futsal League

::: 2007-08 New England Futsal Academy Reservation:

::: Player Information:
Player Name:
Birthdate:
Your Address:	# Street Apt. #
Your City, State, Zip:	,
Home Phone:
Cell Phone:
Email Address:
Email Confirmation:
Player Age:	Gender:
Select Day to Train:
Years Playing Futsal:
Years of Soccer:
::: Parent or Legal Guardian Information:
Parent/Guardian:
Your Address:	House # Street Apt. #
Your City, State, Zip:	,
Home Phone:
Cell Phone:
Email Address:
Email Confirmation:
::: Emergency Contact Information:
Contact Name:
Phone:
Cell Phone:
::: Medical Conditions:
Known Allergies:
Medical Conditions:
::: Consent & Release Section:
Consent for Emergency Medical Aid and Medical Treatment As the Registrant or Parent/Legal Guardian of the above named registrant, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dental Medicine. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being as deemed advisable in the event of an accident or illness during the soccer related activities in which we are voluntarily participating. I, the participant or parent/guardian of a minor registrant, agree that the registrant and I will abide by the rules of the academy, league, its affiliates and sponsors. Recognizing the possibility of physical injury associated with Futsal and in consideration for the Academy accepting the registrant for its Futsal programs and activities (the "Programs"), I hereby release, discharge, and/or indemnify the League, its affiliated organizations (if any) and sponsors, their employees and associated personnel, including the owners of gymnasiums and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrant's participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. Further, I hereby acknowledge that participation in athletic competitions, camps, and/or clinics carries with it certain potential hazards. In consideration for League accepting the registrant for its program, I further release, discharge and/or indemnify the league, its officers, directors and employees, any coaches, assistant coaches, team managers and referees, the facilities in which any such athletic activities are being physically conducted, the league with which I am affiliated, the organization permitting the league to operate, and the institution/facility at which this activity is being conducted, against any and all claims by or on behalf of the registrant as a result of registrant's participation in the Futsal programs. Player / Parent or Legal Guardian Consent Signature: (if signing up online please type in your name and the last 4 digits of your social security number)

::: Additional Instructions:
All of the above information must be filled out. A player's parent or legal guardian must sign the consent found above and submit by payment and receipt by mail to the address listed below. Your online reservation will be confirmed once payment is received. Thank you for your player registration.
::: Payment Area:
Once your information is completed above, press the 'Submit Reservation' button below. An automatic confirmation shall be created. Please print out the confirmation form and submit it with the accompanying payment. Your reservation in the New England Futsal Academy at the Mansfield Sportsplex will only be completed upon receipt of payment with the confirmation form. (Please make check payable to New England Futsal & mail along with a copy of your submitted player information to the attention of Bill Sampaio, 55 Glendale St., Tiverton, RI 02878)