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| Last Name: | First Name: |
| Birth Date: | Age on Sept. 1, 2008: |
| Grade in School-Fall 08: | School: |
| Gender: [ ] Male [ ] Female | |
| Address: | City: State: Zip: |
| Home Phone: | Email Address: |
| THPRD Member Number: | You must have a THPRD number to be placed on a team. |
| List One (1) Buddy: | Phone # Required: |
| (Placement on a specific team is not guaranteed.) | |
| Family Data: | |
| Father's Name: | Work Phone: |
| Mother's Name: | Work Phone: |
| Family Doctor: | Phone: |
| Medical Problems/Concerns: | |
| Emergency - Non-parent Contact: | Phone: |
| Insurance Company: | Group #: |
FEES: | |||
| Registration Fee: | By May 31st: | $65.00 | |
| After May 31st: | $80.00 | ||
| Team Jersey (if needed) U8-U14 only: (T-shirt included in Kick and Chase at no charge) |
$15.00 | ||
| Please circle size needed: | Youth Medium Youth Large Adult Small Adult Medium Adult Extra Large | ||
| Total Registration Fee (please make checks payable to OHSC) | |||
Please mail to: |
Chris Barker, Registrar 5456 NW Preakness Terrace Portland Oregon 97229 | ||