KEARNY RECREATION YOUTH SOCCER
REGISTRATIONS
Kearny Recreation Department
Town Hall
402 Kearny Avenue
Commission Meets on the 3rd
Wednesday of each month
REGISTRATION: Monday, May 22, 2017 to Friday, July 07, 2017 from 9:00 a.m. to 4:30 p.m.
OPEN TO CHILDREN PRE-K TO 8TH GRADE AS OF SEPT 2017
FEE: $35.00 per child BIRTH CERTIFCATE REQUIRED CHILD’S GRADE AS OF SEPTEMBER 2017 SCHOOL YEAR.
OUR PRE-K BOYS AND GIRLS PROGRAM IS STRICTLY INSTRUCTIONAL.
NO REFUNDS ONCE SEASON STARTS
PLEASE BE ADVISED DUE TO OUR LARGE ENROLLMENT THERE WILL BE NO SPECIAL REQUESTS TAKEN TO PLACE YOUR CHILD
WITH A CERTAIN TEAM, CERTAIN COACH OR A CERTAIN CHILD. ALL REGISTRATIONS AFTER JULY 07 2017 WILL BE PLACED ON
A WAITING LIST. KEARNY YOUTH SOCCER NEEDS VOLUNTEER COACH’S. PLEASE FILL IN BOX BELOW IF INTERESTED. A SINGLE
REGISTRATION WILL BE WAIVED FOR ALL COACHES.
Kearny Recreation Youth Soccer Activity Registration Form 2017
PLEASE PRINT ALL INFORMATION CLEARLY
Boy or Girl –please circle
Name______________________________ Address:__________________________Email:_________________________
Date of Birth:______________Age:____________School_______________________ Grade________________________
Home phone:____________________Cell:_______________________Emergency Number ________________________
Health Insurance Carrier________________ Policy No._____________
Does your child play on any travel soccer teams:
YES or NO - must circle one
Yes, I am interested in Coaching, Assistant coach or volunteer
(circle one)
NAME:__________________________________CONTACT NUMBER:__________________________________
Approval and Permission for Photos: I/we the undersign understands and agrees that photographs may be taking during
recreation programs and I/we herby give permission to have his/her photo taken and authorize the use of said photos taken
by the Town of Kearny Recreation Department or its representative to be published in local newspaper or Town’s web page.
YES_____ or NO_______
PLEASE CHECK ONE:
Please read and sign below:
I/We the parents of the above named child, do hereby give my/our approval to his/her participation in any and all activities. I/We do
assume all risks and hazards incidental to the conduct of the activities and transportation to and from the activities: and do further hereby
release, absolve, indemnify and hold harmless the Town of Kearny and the organizers, sponsors, and supervisors: any or all of them. In
case of injury, to my/our child I/We waived all claims against the organizers, the sponsors, or any of the supervisors appointed by them. I/We
likewise release from responsibility any person transporting my/our child to or from the activities. I/we will furnish his/her Certified Birth
Certificate upon request.
Parent/guardian________________________________________Date________________________________
Signature_______________________________________Date_______________________
(Parent or Guardian)
Registered By:_________________________Date:_____________Fee:________Check/Cash/MO
Read & sign revise side