2023 Soccer Registration- Trinity Baptist Church

Please complete this form to register your child in our 2023 soccer season.

Participant Information

Participant's Name

Gender

Please select one option.

Male Female

Birthdate

Age as of September 1, 2023

Please select one option.

3 4 5 6 7 8 9 10 11 12 13 14

Grade

Please select one option.

Pre-Kindergarten Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th Graduated

Parent/Guardian Name

This address will receive a confirmation email

Phone

Address

Authorized Pickup (1)

Authorized Pickup (2)

Permission Release

Please select all that apply.

As parent or legal guardian, I hereby give permission for my child (listed above) to participate in activities offered by—or on the campus of—Trinity Baptist Church.

Medical Information

Emergency Contact Name (1)

Emergency Contact Phone (1)

Emergency Contact Name (2)

Emergency Contact Phone (2)

Allergies, Medical, & Special Needs

Please select one option.

YES NO

Please list any allergies, dietary restrictions, medical or health problems that would affect his/her participation in any activities:

List any medications taken:

Name of child's physician and any other physician who can be consulted in the event of emergency or medical problems involving htis child when parent/guardian cannot be reached:

Physician Address

Physician Phone

Insurance Information

Name of Insurance Company

Insurance Address

Name of Primary Policy Holder

Policy Number

Phone Number of Insurance Company

Payment

***PLEAE BE SURE TO RETURN TO THIS PAGE AND HIT "SUBMIT" BUTTON TO FINALIZE REGISTRATION***

You may make payment in person or online ($50 per child)

Pay Now Online

Medical Release

***PLEAE BE SURE TO RETURN TO THIS PAGE AND HIT "SUBMIT" BUTTON TO FINALIZE REGISTRATION***

Please use this link to esign medical release form (required for participation):

Medical Release Form

Description

Please complete this form to register your child in our 2023 soccer season.

2023 Soccer Registration- Trinity Baptist Church

Description

Please Fix the Following