Registration
Winter 2010 Total Soccer Performance
Central Jersey Celtic FA
Player Information(Please print)
Name__________________________________
DOB___/___/_____ Age___ Sex M / F
Parent Information(Please print)
Name of parent___________________________
Street___________________________________
Town____________________Zip Code________
Phone___________________________________
Email___________________________________
Emergency Contact________________________
Phone___________________________________
Please include relevant medical information in writng with
this application I certify that my child(ren) is/are in excellent
health and are able to participate in physical activity including
soccer. I agree to hold Central Jersey Celtic FA, it’s agents,
employees and contractors harmless from any and all claims
for injuries sustained during my child(ren)s participation
in this program. Permission is granted for my child to
receive emergency medical treatment.
Signed________________________Date_______
Checks should be made payable to Central Jersey Celtic FA
Please send checks & registration forms to
30 Herning Ave, Cranford NJ 07016
Amount enclosed__________________________
Signature_________________________________
