Player Registration – Lisburn Youth Football Club

Name *

First

Middle

Last

Date of Birth *

Age Group *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Medical Information *

Parent / Guardian Name *

First

Last

Email *

Phone *

Relationship *

For the above-named child, I give permission:

To take part in all football related activities.
In the event of an accident or illness, that medical treatment can be administered by a nominated first aider.
That if I cannot be contacted and my child requires hospital treatment, I authorise an adult leader to sign on my behalf any written form of consent required by the hospital. I understand Lisburn Youth will endeavour to make contact with parent/guardians as soon as possible.
That Lisburn Youth FC can take and use photographs for publicity purposes. (Facebook, website etc)

Player Registration Fee *

Price: £ 20.00

Total

£ 0.00

Credit / Debit Card *

Card

Name on Card