HOW DO I SIGN UP?

PLEASE BE SURE TO FILL OUT STEPS 1-5

BRING OR MAIL REGISTRATION FORM AND FEE TO:

Kennebec Baptist Church
09/10 UPWARD SOCCER
REGISTRATION FORM
PARENT/GUARDIAN INFORMATION:
1 Father/Guardian
Work Phone ( )
I would like to assist this league by being a: COACH REFEREE TEAM PARENT

2 Mother/Guardian
Mailing: Drop Off: PARTICIPANT CONTACT INFO: Work Phone ( )
P.O. Box 1690 9808 Kennebec Church Road I would like to assist this league by being a: COACH REFEREE TEAM PARENT

Angier, NC 27501 Angier, NC 27501 3 Emergency Contact

Daytime Phone ( )
Registration may be dropped off at the Church Office, Monday Last Name First Name MI Gender Grade (09-10 school year) Evening Phone ( )
through Thursday from 8:30 a.m. to 2:30 p.m. Please call For a larger print version of these terms and conditions please
before coming. Address Date of Birth
visit www.upward.org/parents
REGISTRATION INFORMATION: Month / Day / Year
PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT.
NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY.
The early registration cost per child for soccer is $55;
Please review and complete the sections below and sign in the space provided to indicate your agreement with all
City State Zip statements made in such sections.

after February 18, the cost is $60. AUTHORIZATION AND RELEASE OF LIABILITY
I, the parent or guardian of the above-named child, authorize the participation of my child in the Upward Unlimited

Deadline for registration is February 27. Home Phone ( ) Cell Phone ( ) athletic program (the “Program”) of the above-named Church. My child will participate in the Upward sport
denoted on this brochure.

Soccer shorts are optional at a cost of $10. I understand that this Program is a nonprofit Christian sports ministry program for youth and that my child’s
participation is voluntary and not essential to completion of requirements of any program, school or government
Parent's Email agency. I understand that the Program is conducted by the Church and its volunteers and staff, including parents
Please make checks payable to Kennebec Baptist Church. of other participating children. I also understand that the Church is solely responsible for all aspects of the
Program including selection and supervision of all persons conducting the Program, and that Upward Unlimited is
Scholarships may be available. not responsible for the Program or selecting and supervising persons conducting the Program. I further
Church understand and agree that my child’s participation in athletic and other activities of the Program necessarily
EVALUATIONS AND SIGN-UPS: (if you regularly attend church, which one?) involves the risk of injury and even death from various causes, including but not limited to accidents, falls,
strenuous and prolonged physical activity, dehydration, illness, collision or dispute with other participants,

Everyone must attend one soccer evaluation.

weather related injuries, playing area and equipment defects, and negligence of coaches and referees. On behalf
of my child, me, and my family, I assume these risks.
Player Information Notes (if any) In consideration of the privilege of my child’s participation in the Program, and on behalf of my child and me as
They will take place at Kennebec Baptist Church as follows: parent/guardian, I hereby release, discharge, hold harmless and indemnify, and covenant not to sue, the Church
and Upward Unlimited, and all of the Church’s and Upward Unlimited’s directors, officers, elders, trustees,

K-5 through 6th Grade Boys/Girls If applicable, circle ONE night your child
deacons, employees, volunteers, insurers, agents and representatives, and all other persons associated with the
Program (including without limitation any other participating churches, sponsors, parents, vendors, coaches and
other game and event workers, officials, drivers, and organizations) as to any and all claims of my child, me and
Saturday, February 13, between 9:30 a.m. and 11:30 a.m. CANNOT practice. other family members for personal injuries suffered by my child, property damage, medical expenses, and
How many years has your child played organized soccer? economic loss arising directly or indirectly out of my child’s participation in the Program, and any first aid, medical

K-5 through 6th Grade Boys/Girls

care or treatment provided to my child in the event my child is injured or becomes ill while participating in
Monday Thursday Friday Program activities, and excepting claims that may not be released under applicable law. This Release of Liability
shall be as broadly construed as allowed by law to include all claims and rights that the child, that I as
Saturday, February 20, between 9:30 a.m. and 11:30 a.m. parent/guardian, and that other family members may have. I am a legally responsible parent or guardian of my
child. If any provision of this Release of Liability is deemed invalid, the remaining provisions shall remain in full
force and effect. This Release of Liability shall be binding on me, my family, heirs, next of kin, legal
Weeknight Evaluations include K5 through 6th Grade representatives, beneficiaries, successors and assigns. I give permission for free use of my child’s name and

Boys/Girls and are divided into last names: SIZING: (COMPLETED AT EVALUATIONS) EVALUATIONS: (COACHES USE ONLY)
picture in broadcasts, telecasts or written accounts for any participation in an Upward Unlimited sponsored event.
MEDICAL CONDITIONS
I understand that participation in the Program may involve strenuous and prolonged physical activity. I agree that

Last Names A through M

my child is healthy and able to participate in the Program activities.
I understand that the Church or its representatives may request health information concerning my child and/or ask

Monday, February 15, between 6:00 p.m. and 7:30 p.m. 10 Yd. Sprint Cone Weave my child to undergo a medical exam. If the Church determines that my child does have a physical or mental
condition that may affect his/her ability to safely and appropriately participate in Program activities, the Church
Soccer Jersey Size (circle one): may determine that my child cannot be permitted to participate. I understand and agree that, while the Church

Last Names N through Z YS YM YL YXL/AS AM AL AXL A2X 20 Yd. Sprint Stationary Passing
desires that all children will be able to participate, such decisions may have to be made out of concern for the
best interests of my child and other participants.

Thursday, February 18, between 6:00 p.m. and 7:30 p.m. CONSENT TO MEDICAL TREATMENT
In the event my child is injured or becomes ill in Program activities, and if I, the parent or guardian of the above-
named child, am not present to make medical decisions, I hereby authorize the Church, its staff, volunteers
Make-up Evaluations Soccer Shorts Size (optional circle one): Breakaway Dynamic Shooting including volunteer parent participants, coaches, assistant coaches, and referees, supervisors and drivers, to
arrange for and consent on my behalf to emergency medical and dental care and treatment, including tests and
Dribble
Monday, February 22, between 6:00 p.m. and 7:30 p.m. YS YM YL YXL/AS AM AL AXL A2X
radiological exams, and surgery, and hospital care and treatment, and to consent to medications for pain and
other conditions as prescribed by medical personnel attending my child. I am responsible for payment of any
medical charges or expenses not covered by my insurance or the insurance applicable to my child (if any).
Please call to set up arrangements to attend the My signature below indicates that all information provided in this form is true and accurate, and that I fully agree
to all statements made on the form, including but not limited to the Authorization and Release of Liability, Medical
Make-up Evaluations. Conditions, and Consent to Medical Treatment. Each responsible parent/guardian should sign.

Make-Up
LEAGUE Evaluations.
SCHEDULE: 4 Signature:
Printed Name: Date:

Practices begin the week of Monday, March 8, 2010. Signature:

Cut here and keep

Printed Name: Date:

First Game - Saturday, March 27, 2010
Awards Celebration - Saturday, May 29, 2010 PAYMENT: 5 If only one parent/guardian signs this form, the following must also be signed:
I affirm that this form was signed by only one parent/guardian because (1) I am the sole parent/guardian
responsible for the care and custody of the child due to death or incapacity of the other parent/guardian or
Participant Fee : $__________ + Shorts : $__________ = Total : $__________ court order, or (2) I have made a good faith effort to obtain the signature from the other parent/guardian but
FOR MORE INFORMATION: have not been able to do so due to causes beyond my control, and I am not aware of any reason that the
other parent/guardian objects to the child’s participation in the Program.

Call Kennebec Baptist Church 919-639-4021 OFFICE USE ONLY PAID AMOUNT PAYMENT TYPE
Signature:
Printed Name: Date:
Email: [email protected] BRC27025 UPW26093