Soccer Event Registration for: 5K Fun Run

Participant Information Adult Registrant or Parent Information
First Name:
Last Name:
Phone: (999-999-9999)
Gender: Male:   Female:
Date of Birth: (mm/dd/yyyy)
Current grade in school - if applicable:
5K Fun Run for All Ages ($30):
First Name (enter again if adult):
Last Name (enter again if adult):
If address is different than participant, please fill in address:
Phone: (999-999-9999)
Cell Phone: If no cell phone, then enter n/a.
Email Address:
Confirm Email Address:
Shirt Size: Youth Small   Youth Medium   Youth Large   Adult Small   Adult Medium   Adult Large  Adult Extra Large    
Please check this box - I wish to pay the above fees by credit card
  Or I will be mailing a check .
Emergency Information
Emergency Contact:
Emergency Phone:
Health Insurance Name:
Physician Name:
Physician Phone:
Health Insurance Policy #:
List any medical conditions, previous concussions, or prohibitions participant has (please include allergies) :

Parent’s/Guardian’s Consent

The minor or participant registrant named above has my permission to participate in the Hempfield Soccer Club, Penn Legacy and/or Seamus Donnelly's Camp programs.  In consideration of your acceptance of my enrollment, I, the player and we, the parents/guardians, individually and collectively, intending to be legally bound, hereby for ourselves and our heirs, executors and administrators waive and release the Hempfield Soccer Club, Penn Legacy, Seamus Donnelly's Camps and facility owners, their agents and representatives, from any and all claims or rights to damages for injuries or losses suffered by me the player, directly or indirectly, in training for, or traveling to and from, or competing in or while attending any future Hempfield Soccer Club, Penn Legacy or Seamus Donnelly's Camps functions.  I acknowledge that the registration and or registration fee does not include accident insurance coverage.  I consent for medical treatment for my child in the event of an emergency.


I, the registrant, or parent/guardian of the participant, a minor or adult registrant of legal age, agree that I and the participant or registrant will abide by the rules of EPYSA and the Hempfield Soccer Club, Penn Legacy, Seamus Donnelly's Camps, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer, and in consideration for the EPYSA and Hempfield Soccer Club, Penn Legacy and or Seamus Donnelly's Camps accepting the registrant for its soccer programs and activities (the “Programs”).  I hereby release, discharge and/or otherwise indemnify the EPYSA, and Hempfield Soccer Club, Penn Legacy, Seamus Donnelly's Camps and its affiliated organizations and sponsors, their employees and associated personnel, including owners of fields or facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of the registrants or participants participation in the Programs, and/or being transported to or from the same which transportation I hereby authorize.

By submitting this form online, I accept and acknowledge the consent and release information,  and I have provided correct information for registration.

You will receive a pop-up of this completed form after submitting. Please print and bring to first date of this event. Checks should be made payable to Penn Legacy, P0 Box 216, Landisville, PA 17538

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Please wait for window with completed form to appear - then print 2 copies.
one for your receipt and one to sign and bring to the first session. A copy will also be emailed to you. (shirts may not be available for those registering after the deadline)