FTC Winter ID Clinic Registration 2020 & 2021

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Please fill out this form to register for the Five Towns College Soccer ID Clinic for 11th and 12th grade girls. This clinic will give players the opportunity to train with college coaches, and provide information on the college recruitment experience.

  • Location: Five Towns College - 305 N Service Rd, Dix Hills, NY 11746

  • Date: Sunday, December 15th

  • Time: 10 AM - 1 PM. Registration starts at 9:30 AM.

Athlete Contact Information

Education

First Parent/Guardian Information

Second Parent/Guardian Information

Emergency Contact

Authorized to pick up? *

Concerns and Comments

Academic and Behavioral

Does the participant exhibit any behaviors that may interfere with participation in this program? *
Does participant have any special needs or require special accommodations? *

Head Injury/Concussion

Has participant ever experienced a traumatic head injury, had a hit to the head that caused headache, prolonged headache, dizziness, nausea, confusion, unconsciousness, memory loss or been told he/she had a concussion? *
Has participant ever had a head injury or diagnosed concussion (i.e. bell rung, ding, head rush)? *

Health/Medical

Has participant ever been told by their health care provider they have asthma? *
Does participant have any ongoing medical conditions like asthma, seizures, sickle cell trait or disease, anemia, diabetes, infections or other? *
Has participant ever had any injuries that may affect participation in a program or activity? *

Agreements

Agreements must be read and electronically signed by a parent/guardian. For each of the agreements below, please read the terms, and type your name to confirm. 

Permission to Treat

Parent/Guardian - Signatory must be 18 years of age or older

Media Release

Parent/Guardian - Signatory must be 18 years of age or older

Parent Guardian Waiver

Parent/Guardian - Signatory must be 18 years of age or older

In addition, the Five Towns College Waiver of Liability/Permission/Medical Release Form must be filled out and signed by a parent/guardian. This form must be printed and brought to registration the morning of the clinic. Please click here to download the form.

* required field