Osceola Soccer Club Registration Form – City of Osceola Arkansas

Player Name *

Player Birthday *

Player Gender *MaleFemale

Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Parent Name *

Parent Name #2

Email *

Cell Phone *

Would you help coach at practices?YesNo

Which Programs are you Registering For? *Osceola City Stars (plays in Jonesboro)After School Skills Academy (Osceola School District grades 1-4; Thursdays in August)

Consents *I/We have read, understand and agree to comply with the Consent for Medical Treatment (Minor) as outlined belowI understand that NO PETS ARE ALLOWED at soccer events, with the exception of service animalsI understand that NO SMOKING is allowed at any practice or game facility, in Osceola or JonesboroConsent for Medical Treatment (minor): As the parent or legal guardian of the above named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

Does Child have medical insurance? *YesNo