Present

CHALLENGER SOCCER

2003 Registration Information

Don’t miss out on all the Action!!!

Challenger Soccer

This program is for individuals with developmental and/or physical challenges

REGISTRATION:You can register in person or by mail! If mailed in, your entry form must be accompanied by the entry fee. For additional information, please call 764-3424.

In Mail / In Person:Central Park Office

1000 Krenek Tap Rd.

College Station, TX 77840

Registration will be accepted: September 2 – 12

8:00 a.m. – 5:00 p.m. weekdays

FEE:$5.00 for each child. Full scholarships are available.

GRADE:K-12th grade

SEASON:6 Sundays (Sept. 21, 28, Oct. 5, 12, 19, 26) from 4:00 PM – 5:30 PM

4 Tuesdays (Sept. 23, 30, Oct. 7, 14) from 6:00 PM – 7:30 PM

Rain out dates if needed (Sundays, Nov. 2, 9, 16) from 4:00 PM - 5:30 PM

LOCATION:Anderson Soccer Fields (900 Anderson, College Station, TX 77840)

LEAGUEFormat of the league will be tailored to the needs of the individuals. We will have FORMAT: activities to develop skills & advance towards games. Wheelchairs, walkers, and

crutches are welcome.

UNIFORMS:T-shirts are provided for all participants.

SPECIALPlease let us know of any special request that you have by indicating it on the attached
REQUESTS:registration form.
HOW/WHEN A program representative will be in contact with you after registration is complete to give
WILL YOU BEmore information about practice and times. If you have not been contacted by Sept. 18,

CONTACTED:then call the parks office at 764-3424.

IF YOU HAVEA program representative will be available for contact in most instances. You may also

QUESTIONS:contact anyone from our Challenger Sports Committee: Ruth Vanoye 680-0122 (en Español), Becky Powell 694-0964, Lisa Olivieri 696-0958, or Robyn Battle 693-9151.

STAFF:Recreation Supervisor, David Hudspeth 764-3424

Assistant Athletic Supervisor, Patrick Hazlett 764-6386

Athletic Assistant, Shelby Smith 680-8631 and Laci Stephenson 260-9098

COACHES/The Challenger Sports Committee will be providing volunteers to help run the program

INSTRUCTORS:and teach skills to the individuals.

CHALLENGER SPORTS

2003 ENTRY FORM

 BASKETBALL BOWLING SOCCER

Fee $5:  Check here if full scholarship is needed.

Child’s First Name: ______Last: ______Nickname: ______

Address: ______

City: ______Zip: ______Sex: MaleFemale

Age: ______Birthdate: ______School: ______

Both Parents’ Name: ______

Mom’s Day Phone: ______Dad’s Day Phone: ______

Night Phone: ______Other Phone: ______

Mom’s email: ______Dad’s email: ______

Alternate Person’s Name ______

Day Phone: ______Night Phone: ______

Other Phone: ______Email: ______

Special Requests:______

T- Shirt Size:

Youth S / Youth M / Youth L / Adult S / Adult M / Adult L / Adult XL / Adult XXL

In consideration of participation in the CMN Challenger Sports Series, we hereby waive and release any and all claims for damages we may have or that my minor child ______may have against the City of College Station Parks and Recreation Department, for any and all injuries suffered to my child while participating or practicing. Additionally, I allow the City of College Station to use any photographs of my child participating in this program for advertising and promotional purpose.

Parent/Guardian Signature ______Date ______

WE NEED YOUR HELP!!! If you are willing to help, please print your name below. A criminal background check is required for all coaches.

Please circle one:Head coach Assistant CoachBuddy

Name: ______T-shirt size:MLXL2XL3XL

Phone (1): ______Phone (2): ______E-mail: ______

Date of Birth (M/D/Y) ______Gender: MFDrivers License #/State: ______

Please Complete Back Page!

General Information

Full Name ______

Age ______

Ambulation

Walks Assisted Walks Unassisted

Walks Using ( Walker Crutches Braces)

Wheelchair ( Manual Electric)

Transfers ( Alone Needs Assistance)

Communication

No Problems Non-Verbal Sign Language

Limited abilities, but can communicate daily needs

Communication Device ______

Vision Normal Limited Blind Glasses

Hearing

Normal Deaf Hard of Hearing Hearing Aids

Behavior

No Problems

Problems Triggered by ______

______

Positive Reinforces ______

Discipline: Withhold Privileges

Time Out ( ______minutes)

Other: ______

Seizures

None One or two as a small child

Type ______

Last one ______

Usual Frequency ______

Usual Duration ______

Pre-Seizure Activity ______

Triggered by ______

______

Medications______

Chief Diagnosis (LIST ALL e.g. Seizures, Asthma, MR, CP, A,)

  1. ______
  2. ______
  3. ______
  4. ______
  5. ______

Other Comments or Concerns:

______