technical training program

REGISTRATION FORM

Please submit payment and the below registration form prior to commencement of sessions. Fee $125.00.  Early Bonus Registration fee $ 120.00 prior to Jan 13^th, 2010.

Cheques payable to FC Northwest.

Mailing Address:

FC Northwest

2 Mirabelle Road

West St. Paul, MB. R2V 4E9

Information posted @ www.fcnorthwest.ca or for any inquires

email: janwilks@shaw.ca

Name:                                                                                          Year of Birth: ______Gender:  M  F

Address:                                                                                      Postal Code: __________________

Phone:                                                                          ____________________________________

            (Home)                         (Work)                                   (Cell)

Parents Names: __________________________________ Email: _________________________      

Shirt Size: _________ Goalie: ______ Coach & Club name: ______________________________

Any limiting Health Factors:  No Yes      If yes please specify: _______________________________

In case of emergency please supply two names and phone numbers if different than above.

1)_____________________________________  2)____________________________________

Release:  The undersigned being the parent or legal guardian or the child listed above, do hereby remise, release, and forever discharge the FC Northwest Soccer Club and its agents and employees of and from all manner of action, causes of action, claims or demands in law or in equity which we may hereafter have for and cause, matter of thing and particular by reason of injuries suffered by the said applicant, by reason of an accident or illness occurring during soccer clinics or other events and programs sponsored or conducted by the FC Northwest Soccer Club.

I understand that by completing this form the FC Northwest Soccer Club is collecting certain personal information about my child, me and other members of my family including if necessary my Manitoba Health Personal Health Identification Number (PHIN) and any medical conditions experienced by my child.  I also understand this information will be used only for the purposes of administrating the FC Northwest Soccer Club player development and in instructional programs.  I herby consent to such collection, use and disclosure of this personal information.

Signature of Parent or Legal Guardian

______________________________