The After School
Program
Registration Form
Player’s Name:_________________________________
Age:___
Sex: M
F
School:___________________________Grade:__________
Parent’s Social Insurance
#:__________________________
Address:____________________________
____________________________________
____________________________________
Postal Code:___________________
Telephone#:______________________(Home)_____________________(Cell)
_________________________(Work)
Email:______________________
Emergency Info:
Contact:________________________
Telephone:_______________________
Allergies ? _______________________ Medicaire
#:_____________________
Player’s T-Shirt Size: (please
circle appropriate size)
Child: Small Medium
Large
Adult: Small Medium
Large
I Would Like to Register for :
(Please Circle)
Fall Session Mondays
Tuesdays Both Days
Winter Session Mondays
Tuesdays Both Days
Spring Session Mondays Tuesdays
WISS Platinum All sessions
I_____________________________________,
attest and verify that my child(ren),
______________________ is (are) physically able to participate in The
West Island Soccer School. I voluntarily assume all risk of any
accident or injury to my child which may arise out of
his/her/their participation in this program: henceforth intending to release The
West Island Soccer School and any personnel associated with this
program from any liability that may result from his/her/their participation.
Signature Date
*Please print and fill out this form
and mail it to:
The
53 Montée
Ste Marie,
Ste Anne de Bellevue, QC
H9X 2B7