E-Soccer Player Registration Form 2019 PLAYER INFORMATION* (One registration form per child) *Participation is on a first come first serve basis and space is very limited for this program. Last day to register is February 15 or until space is filled, whichever occurs first. Registration Fee (required) $15 First Child$10 Add'l Child Last Name (required) First Name (required) Gender (required) MaleFemale Age (required) Shirt Size (required) YouthAdult - - - - - - XSSMLXL PARENT or GUARDIAN INFORMATION Name (required) Phone (required) Alt Phone (required) Email (required) EMERGENCY CONTACT INFORMATION (must be 18 or older) Name (required) Relation (must be 18 or older) (required) Phone (required) QUESTIONNAIRE Please answer the following questions as they apply to your child or children. If more than one child will be participating in the E-Soccer Program, complete the information on each. If more space is needed, please include an attachment. All information below is held strictly confidential, and is used solely for the purpose of child placement in the E-Soccer Program. Has your child participated in group sports before? (required) YesNo Does your child have a 'special need' or a medical diagnosis (e.g. allergies, asthma, hemophilia, heart condition, history of respiratory illness or other significant medical condition, etc) related to their ability to participate in a sports program that the E-Soccer officials should be aware of? YesNo If yes, describe and provide clearance from a doctor. Please select any of the following conditions that apply to your child: ADD/ADHDHigh functioning Autism or Asperger's Syndrome or PDD/NOSModerate to severe AutismDown Syndrome or other developmental disabilityCerebral PalsyOtherNone of the above Please indicate the level of one on one instruction you feel your child will need to successfully participate in the E-Soccer program 0-25% (Child can follow direction of coach with little or no individual assistance)25-50% (Child is fairly independent in following instructions but may need some extra assistance. For example, has difficulty with transitions or needs help with balance at times)50-75% (child needs a coach directly assisting or monitoring them over half of the time)75-100% (Child needs either a coach directly assisting or monitoring them all of the time) Please check the top 3 most important goals for your child's participation in the E-Soccer Program Inclusion / social interactionBalance and coordinationStrength and enduranceGain skills for play in regulation competitive soccer gamesEffort, determination and perseveranceEmpathy, acceptance, kindnessSelflessnessLeadership development / Train to become a junior coachOther By checking this box, I acknowledge that I have read and understood the Release of Liability and give full consent. Please make sure you click on the link on the next page to make the payment online and complete the registration.