2018 Temporary Registration Form
First Name: / Last Name:
Parent(s) Name(s):
Address:
City: / Postal Code:
School Attended: / Grade:
Tel: / Cell:
Date of Birth: / (DD / MM / YYYY)
Parents’ Email:
Medical or Dietary
Conditions: optional / Male
Female
Previous Experience: / Competitive / Years / House League / Years
Club/Org last played for:
Rating: / Beginner / Fair / Good / Excellent
Position: / Forward / Mid / Defence / Goal
Sessions: TBA (choose the timings that you are available) / DAY(s) TBA
This Temporary form is for ages from U10 (08) – U21 (97) age group
All sessions will held at the London Marconi Soccer Facility
I, the undersigned parent/legal guardian of the above named player, do hereby consent & agree to his/her participation in the London Marconi Soccer program. It is agreed that London Marconi Soccer / Marconi Club of London / Sponsor(s) / League & District Associations assume no responsibility for any injury as a result of such participation or in travelling to & from such participation. It is further agreed that the player & the parents or the legal guardian, will comply with all rules & regulations relating to the soccer program. Parents sign for U18 players only.
Signature of Parent / Legal Guardian / Date
London Marconi Soccer Use Only – Do NOT write in this area
Division / Age : / Mini-Soccer Academy / (includes T-shirt & Certificate of Completion)
Entry Fee: / TBA / Cash ¨ / Cheque ¨ # ______
TBA / Cash ¨ / Cheque ¨ # ______
Received by: / Date:
LMS Registrar: / Date:
Cheques made payable to: London Marconi Soccer & mailed to c/o TBA
Street Address: Mailing Address: For further information, call Mario 519-520-5073
London Marconi Soccer London Marconi Soccer Visit our website: londonmarconisoccer.com
120 Clarke Road c/o 970 Moy Crescent c/o Tel: 519-455-7950
London, ON N5W 5E1 London, ON N6G 0B6 c/o Fax: 519-455-7958