Portland High School Co-ed Soccer Club
2008 Fall Player Registration
Please Print Clearly - All information must be complete to validate your registration
Fall Player Fees: Without Uniform $95 With Uniform $125
Save $5 off Fee by registering online at www.portlandhighschoolco-edsoccer.com
Please send check made out to: Portland High School Co-ed Soccer Club
Mail to: Karla Bergeron, 5228 NE Simpson St., Portland, OR 97218
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____________________________________ _______________________________ __ __/__ __/__ __
First Name Last Name Date of Birth
______________________________________ __________________ ____________ __________________________
Address City Zip Code Telephone
_____________________________________________________________________ Gender: ( ) Male ( ) Female
Email Address
__________________________ _______________________________________________ __________________________
Mother’s (or Guardian) Name Address (if different from above) Work or Cell Phone
__________________________ _______________________________________________ __________________________
Father’s (or Guardian) Name Address (if different from above) Work or Cell Phone
____________________________________________ __________________________ __________________________
Person (other than parents) to contact in an emergency Relationship Telephone
Volunteer Support
We ask for active participation of parents in our program. Please let us know the area(s) in which you would be willing to help.
Coaches must be at least 21 years old and assistant coaches at least 19 years old.
( ) Coach ( ) Assistant Coach ( ) Team Parent ( ) Club Board ( ) Equipment ( ) Uniforms ( ) Other _______________
____________________________________ ____________________________ ________________________________
Volunteers Name Telephone Email
Player Information
High School you will attend 2008/2009____________________________ Year in School 2008/2009: FR SO JR SR
Preferred Playing Position_____________________________________________ Years Played_________________________
Do you need a uniform (2 jerseys, short, & socks)? ( ) Yes ( ) Small ( ) Medium ( ) Large ( ) XLarge ( ) XXLarge
( ) No Jersey number you have #_______
Did you play in this league last fall? ( ) Yes ( ) No Coach or Team Name_________________________________________
Coach Request__________________________________ Teammate Request _____________________________________
Additional Comments:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
For additional information email Karla Bergeron at karla.bergeron@comcast.net