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00 Port Clinton Youth Soccer Fall 2013 Registration East Suburban Soccer League Deadline July 31 2013 Season Dates Sept. Fall Registration Boys Girls Leagues - Ages 4-13 Player placement is based on player s age as of July 31 2013 Fees Registration 6-9 yr olds 35. 3 - Oct. 13 2013 Bumblebee 4 5 yr olds 25. 00 No registration accepted late. City Mail in Registration Return with appropriate fees to P. O. Box 234 Port Clinton Ohio 43452 Questions Contact Abby or Steve Lukac 419 960-7010 Board Members Abby Lukac Steve Lukac Lori Rumbarger Dave Kobel Jessica Lake President Treasurer Dist. Rep* Trustee Fathers name School Attending State Mothers Name Age Divisions U6 U8 U10 U12 U14 Male Female Last Name Address Late registration will be accepted only if needed to fill teams. MI First Name Grade Spring Zip Telephone OR Legal Guardian s Name Age on July 31 2013 Date Of birth E-Mail Address Name of Brother/Sister in same age bracket Shirt Sizes Circle One Youth YS 6-8 YM 10-12 YL 14-16 Note Players will be placed on a team Based on a blind draw. Players are responsible for shin guards. Adult AS AM AL AXL AXXL Parents - If interested please circle one of the following Your child will appreciate your time and effort Head Coach Assistant Coach Referee Volunteer administrative duties We hereby agree that the soccer association for youth SAY its members coachs or officers shall not be liable for any injury or loss which my child may sustain while participating in activities of any kind whether sponsored by or under the supervision of SAY and we agree to indemnify and to hold SAY it members coaches officers or designates of any kind from any claim whatsoever. CONSENT FOR MEDICAL TREATMENT As a parent/legal guardian of the above registrant I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life or well being of my dependent. Does the child have any allergies or require special medications YES NO Explain Parent/Legal Guardian Signature Date. 3 - Oct. 13 2013 Bumblebee 4 5 yr olds 25. 00 No registration accepted late. City Mail in Registration Return with appropriate fees to P. O. Box 234 Port Clinton Ohio 43452 Questions Contact Abby or Steve Lukac 419 960-7010 Board Members Abby Lukac Steve Lukac Lori Rumbarger Dave Kobel Jessica Lake President Treasurer Dist. O. Box 234 Port Clinton Ohio 43452 Questions Contact Abby or Steve Lukac 419 960-7010 Board Members Abby Lukac Steve Lukac Lori Rumbarger Dave Kobel Jessica Lake President Treasurer Dist. Rep* Trustee Fathers name School Attending State Mothers Name Age Divisions U6 U8 U10 U12 U14 Male Female Last Name Address Late registration will be accepted only if needed to fill teams. Rep* Trustee Fathers name School Attending State Mothers Name Age Divisions U6 U8 U10 U12 U14 Male Female Last Name Address Late registration will be accepted only if needed to fill teams. MI First Name Grade Spring Zip Telephone OR Legal Guardian s Name Age on July 31 2013 Date Of birth E-Mail Address Name of Brother/Sister in same age bracket Shirt Sizes Circle One Youth YS 6-8 YM 10-12 YL 14-16 Note Players will be placed on a team Based on a blind draw.

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