Soccer

Indoor Soccer for grades 2 - 4 at Cornwall Consolidated School

Tuesdays- January 7, 14, 21, 28 February 4, 11 from 6:15-7:15p.m.

Guided Instruction Through Soccer Scrimmages

Coach Jen Naylor has coached for over 10 years and played Div. 1 college soccer

There is no cost for this program.

But Space is Limited! Deadline January 1st.

Please fill out one for each child.

Cornwall Park and Recreation Activity Form

Child's Name *

Please select your child’s grade. *

2nd

3rd

4th

Allergies or disabilities that supervisor should be aware of

Parent/Guardian Name *

Email Address *

Address *

Best Contact Phone Number *

2nd Parent/Guardian Name

Email Address

Address

Best Contact Phone Number

In case of an emergency and you cannot be reached, please provide another person for emergency contact:

Emergency Contact Name *

Relationship *

Emergency Contact Phone number *

PHOTO RELEASE I give permission to have my child’s picture appear on the Cornwall Park and Recreation website and Facebook page while engaged in Park and Recreation activities. *

Yes

Signature *

RELEASE AND EMERGENCY MEDICAL AUTHORIZATION

The undersigned, for themselves and/or their children as hereinafter named, hereby releases and discharges the Town of Cornwall, its officers, commissioners, commissions, employees, and agents from any and all liability for any loss or damage to property of or bodily injury or death to the undersigned arising from or related to the undersigned’s participation in the town-sponsored activity hereinafter specified; and
The undersigned does hereby further knowingly, intentionally, freely and expressly:

assume the risk for any loss, damage, bodily injury or death arising from, related to, or occurring during the undersigned’s participation in the town-sponsored activity hereinafter specified; and
releases the Town of Cornwall and its officers, commissioners, commissions, employees and agents from any and all liability for any such loss, damage, bodily injury or death to the undersigned; and
waives any claim or cause of action which the undersigned may have against said Town or its officers, commissioners, commissions, employees and agents for any such loss, damage, bodily injury or death.

If the undersigned cannot be reached, the undersigned does hereby give permission to the physician selected by the Recreation Department of the Town of Cornwall or program supervisor to hospitalize, secure proper medical treatment for, and/or to order injection, anesthesia, or surgery for myself and/or my child as participants in the town-sponsored activity hereinafter set forth.

Parent/Guardian Signature *

Date *

Thank you for registering.

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Soccer

*Please fill out one for each child.*

Cornwall Park and Recreation Activity Form

Please fill out one for each child.