Ottawa St. Anthony Soccer Program

523 St. Anthony Street, Ottawa K1R 6Z9

Tel. (613) 567-9681 - Fax (613) 233-5839 - www.ottawastanthony.com
Player's Name
First Name
Middle Initial
Last Name
(Parent/Guardian)
Fist Name                    Middle Initial                   Last Name
Address
Street Address
City
Province and Postal Code
Player's Records
Date of Birth (DD/MM/YYYY)		 CD-0773-
Team Number
OSA Registration Number
Telephone Numbers
Home Telephone
Cellular
Work Telephone
E-mail / Fax
                    Email Address                                              Fax Number
Player Status Current St. Anthony Player  New/Returning Player     Player GENDER:Male  Female   
  Year last registered: Club last registered with:
Has Player ever registered outside Canada?:YesNo    Where and When?:
Player HEALTH CARD:Yes  No      Health Card Number (Optional): 
Medical Problems Coach Should be Aware of:
Emergency Contact

Relationship

First Name

StreetAddress

Daytime Phone

Middle Initial

City

Cellular

Last Name

Province / Postal Code

Evening Phone
Fall 2006 and
Winter 2007
Development
Registration Fees
Fall / Winter: Oct. 17, 2006 - Mar. 27, 2007 ($190)

Notes: Fees include End-of-season Dinner at St. Anthony Soccer Club for participant and one (1) guest.

Please make cheque payable to: Ottawa St. Anthony Soccer Program

The undersigned, as registrant or as the parent/guardian of the registrant, hereby waives any claim or right, releases and agrees to indemnify and save harmless Ottawa St. Anthony Italia Soccer Club Inc., the Ottawa-Carleton Soccer League, the East Region Soccer League, the Eastern Ontario District Soccer Association, and their directors, organizers, coaches, referees, sponsors and other officials, relating to the participation of the registrant in the activities of the named organizations. It is furthermore agreed and understood that the player named above has registered with Ottawa St. Anthony Italia Soccer Club under his/her own free will.

Signature: Date:
Please verify the above information, print the form and send a signed copy along with payment to the address above.