WINTER INDOOR SOCCER LEAGUE
(WISL) 2014 REGISTRATION FORM
Send this form with credit card information or check payable to WISL to: Dave Fromer/WISL, 147 Elm Ave, Mill Valley 94941 Or: fax with CC info to 415-388-1581
PARENTS: This form must be filed out completely so that we can place your child appropriately. Please call (415)383-0320 if you need assistance.
Player's Name: ______________________Male: __ Female: __Age: __ Birthdate: _________ Fall 2013 School & Grade___________________ Address: ______________________City: ______________ Zip: ______
Home Phone #: _________________ Work/Cell #: ____________
Email Address: ______________________________________
Player's Soccer Experience: Recreational/Beginner __ Intermediate__ Advanced__ Competitive-upper House/Select __
Age Group in Fall '13 league (i.e., U6, U12):___________
Insurance Carrier: ______________ Policy #: ______________
Emergency Contact: ________________ Emergency Tel #: __________
TEAM: _________________ COACH: ___________________
PARENTS: Are you willing to coach/assist or serve as team parent?
Please specify: coach ___ asst coach ___ team parent ____
PLEASE NOTE: scheduling conflicts (Sunday school, church, etc.) and/or requests for teammates. We will accommodate when possible. _________________________________________________________
How did you hear about our Indoor Soccer program? _______________
FEES: Postmark/Fax by 12/7/2013 $175
Postmark/Fax after 12/6/2013 $200
Waitlist is initiated December 13th. A full refund is given if we cannot place your child.
Please include your check w/ registration form or include credit card information here:
__ Visa __ Mastercard or Check # ______ Payment Amount: _____
Card # ______________________________ Exp. date: ______
Name on Card: _______________Signature: _________________
I hereby authorize the staff of the Winter Indoor Soccer League program to act for me according to their best judgment in any emergency requiring medical attention and I hereby waive and release the WISL and the Tamalpais Union High School District from any and all liability for any injuries or any illnesses incurred while participating. I have no knowledge of any physical impairment that would be affected by the above-named players's participation in the program.
X ______________________________________ Date: _____________
Signature of Parent or Guardian