Mt. Prospect Park District
2017 Spring Pre-K Soccer League
4-5 Year Olds
(Please Complete Both Sides)
Step 1: Family Information
Family’s Last Name:
Player(s) Last Name (only if differs from family)
Home Address:
City:
Zip:
Parent/Guardian First Name(s):
Home Phone
Alternate Phone
E-Mail Address (es)
Step 2: Player (s) Information
Player First
Name (s) WRITE
NAMES BELOW IN
BOX(ES)
Date of
Birth
M/D/Y
Age
School
Team/
Coach
Played For
*Reciprocal
Friend
Request
JERSEY SIZE
(circle one)
Player #1
 Boy
 Girl
First Name:
Jersey
YS AS
YM AM
YL
Player #2
 Boy
 Girl
First Name:
Jersey
YS AS
YM AM
YL
Player #3
 Boy
 Girl
First Name:
Jersey
YS AS
YM AM
YL
*Reciprocal Friend Request – The Mt. Prospect Park District does provide the opportunity for players in our youth soccer program to make
a friendship request to be paired on a team with one other player in the league. This request is for a set of 2 players only and each player
must reciprocate the request at the time of registration. Requests involving 3 or more players will NOT be honored.
Step 3: Figuring Fee
Total # of players registered:
X
Res $60 / NR $65
(Circle one)
Less Multiple children in a family $10 off 2 nd, 3rd etc..child
(=Total # of players registered – 1) X $10)
$
Total Amount
Code: 29906
Turn Over to Complete Registration Form
Youth Soccer Registration Form (Cont)
$(
$
)
Step 4: Questions
Question
What do you believe is your child’s
athletic ability? 1 = little or no athletic
ability/ 5= very athletic (“X” one)
Has the player played soccer before?
(Yes/No)
If the player has played before, how
many years has the player played?
Has the player played or is currently
playing travel soccer?
Do you have any conflicts your coach
should be aware of?
Do you have any medical conditions
your coach should be aware of? (Y/N) if
Y – please explain:
Player #1
 1
 2
 3
 4
 5
 Yes
 No
 1-2 yrs
 3+ yrs
 Yes
 No


Yes
No
Player #2
 1
 2
 3
 4
 5
 Yes
 No
 1-2 yrs
 3+ yrs
 Yes
 No


Yes
No
Player #3
 1
 2
 3
 4
 5
 Yes
 No
 1-2 yrs
 3+ yrs
 Yes
 No


Yes
No
Step 5: Sign Waiver
I hereby agree to abide by all Mt. Prospect Park District rules and regulations as they pertain to the Park District facilities
or services, and any resulting consequences for failing to abide by them. By their very nature, many Park District programs
involve body contact, substantial physical exertion, emotional stress and/or use of equipment, which represents a certain risk of users. It
is recommended that you check with your physician prior to participating in these activities. The Park District does not provide insurance
protection for participants in Park District activities. Registration in any Park District program or purchase of any Park District facility use
pass or admission assumes full responsibility on the part of the registrant for any risk, implicit or direct, by participation in said activity or
facility. Further, the registrant agrees on the following:
1. I fully recognize the risks of injury or illness inherent in this program and represent to the Park District that I offer my authority
for me or for my child to participate.
2. I hereby release and discharge the Mt. Prospect Park District and its officers, directors, employees and volunteers from any and
all claims, actions or causes of judgments whatsoever including attorney’s fees and costs, which might arise from said
participation.
3. I hereby execute this release and acknowledge that such participation is at my own risk.
4. I hereby grant emergency treatment for myself or child if I cannot be reached
SIGNATURE:
DATE:
Step 6: Volunteer Information
Volunteers are instrumental to the success of the youth soccer program. Please let us know if you are willing
to help this season out as a coach, assistant coach, or team aid.
I am interested in volunteering for the youth soccer program as:

Head Coach – Your Name/phone number:

Assistant Coach - Your Name/phone number:
Head Coach/Assistant Coach – Best Email: ________________________________
(Please Complete Both Sides)