In order to protect your privacy and security, The Soccer Patch wants to make every effort to ensure that information about you is used with your permission, or with the permission of an adult if you are a minor.

If you would like to have your email address posted on our site, please fill out the this form and mail it to us at the address provided below or return it via email.

Your email address will not be displayed without your permission.

Additional Privacy Information is available.

___   I am 18 years of age or older and give The Soccer Patch permission
        to list my name / email address (as indicated below) on their website.

Your name as you would like it to appear (please print):

      ____________________________________________________

Your email as you would like it to appear (please print):

      ____________________________________________________

Today's date :         ___________________________________________

Your signature :       ___________________________________________

___   I am the parent (or guardian) of a child under the age of 18 years and give
      The Soccer Patch permission to list my child's name / email address
      (as indicated below) on The Soccer Patch website.

Child's name as it should appear(please print):

      ____________________________________________________

Child's email as it should appear (please print):

      ____________________________________________________

Today's date :         ___________________________________________

Parent's/guardian's name (please print): _______________________________

Parent's/guardian's signature :       ________________________________

Inquiries for the Help Needed section that are sent to us without the completed, and signed, Permission Form, will be posted, but will not include information about the donor's email address. Thanks for your cooperation!