JRGC & Soccer Registration Form

9-week Fall Session 2023

Athlete's Name:______________________________ Age:___

Birth Date: _______________ Parent Name: __________________________

Cell Phone ____________________

Emergency contact Name:___________________

Phone: _________ Cell Phone:_________________

Address: Street:_________________________________________________

City: _______________________________ State:_____ ZIP:________

Phone: ____________________ E-mail: ___________________________

Dates: September 16th - November 11th, 2023


(mark your preference)

I have enclosed a check for: [ ] $450

Please make checks payable to Nicolae Piperea

Health Certificate:

My son/daughter is in good health and has my full permission to participate in the Soccer classes. He/she has no previous sickness, illness, or disease or bodily injury that is adverse to participation in the Soccer classes. It is understood that the medical insurance policy insures against loss resulting directly from participation in the Soccer classes not exceeding $2000 and after your own insurance has been used. The law requires that parental permission be obtained so that urgent medical attention can be administrated to minors. The following consent form should be signed by the parents in order that such procedures as be necessary may be conducted without due delay. However, no major operation will be performed, except in extreme emergency, without the parents contacted and fully informed. I hereby give my permission for such diagnostic and therapeutic procedures as maybe deemed necessary for my child and also, to present information concerning his/her medical condition to our responsible soccer coaches when deemed desirable.

Signature: ___________________________