Cheektowaga Soccer Club
P.O. Box 1865 - Cheektowaga, New York 14225

Please complete all of the fields on the application, print the application, and mail it with your registration fee. Leave the fields blank to fill out the application by hand.
Last Name:
First Name:  

MI:
Email:

Address:

Town/Zip:

     

Phone:

Birth Date: / /

Age in Sept :

School:

Grade:
Gender:

     M______   F______

Registering for (Check all that apply)

Fall House League
Winter House League
UNIFORM SIZE: 

     AXL   AL   AM    AS                             YL   YM    YS

Do you have interest in playing travel soccer?                            Y ____  N____
Father's name: __________________________        Phone: ______________________                                    Mother's Name: _________________________        Phone: _______________________                                Emergency Contact: ________________________  Phone: ______________________                              Relationship to Applicant: _______________________                                                         

Medical Considerations:__________________________________________________                             Insurance Coverage:_____________________________________      

Would you like to coach or assist a house league team?  Y_____   N_____   

Has this child ever played soccer before?   Y ____   N____ , If so how many years? ______

Has this child ever registered with CSC before?    Y_____   N_____  

What teams/leagues have they been involved with? _______________________________         

How did you hear about CSC? ____________________________                                 

***By signing this waiver, I give my permission to the Cheektowaga Soccer Club to use my child's photograph in publications of the association, which include info. & public relations materials, such as newsletters & our website (www.cheektwagasc.com) This release is in effect until such time I request in writing that I want to discontinue the use of my childs photos.*** I understand that participation in youth soccer presents a risk of injury, and I agree to hold harmless and indemnify the Cheektowaga Soccer Club,it's board, officers, coaches, and members, for and against any and all claims of any nature from my child's participation in the soccer program. I certify that my child has been declared by a physician to be physically able to participate in the soccer program without any restrictions. A $25 fee will be applied to all returned checks.

Parent or Guardian's Signature: __________________________________         

Print Parent or Guardian's Name: ________________________________            Date: ______________________