Southbridge Youth Soccer Association

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Registration Form Rev 5=

Season (circle one) Fall / Spring<= span style=3D'mso-spacerun:yes'> = &nb= sp; = &nb= sp; Date: ____/____/_____

Child= ’s Last Name: _________________________ &= nbsp; &nbs= p; Sex (circle one) M / F<= /p>

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Child= ’s First Name: _________________________ = &nb= sp; Date of Birth: ____/____/_____

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Addre= ss: _________________________________ &nbs= p; &= nbsp; Phone #: _____- ___________

Shirt= Size: Youth: S<= span style=3D'mso-spacerun:yes'> M L Adult: S M= L XL (circle one) = <= /span>

Have = you played organized soccer before? Yes / No (circle one) = <= /span>

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Mothe= r’s Name: _______________ &nbs= p; &= nbsp; Father’s Name: ___________________

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Busin= ess Phone #: _____-_______ &nb= sp; = Business Phone #: _____-___________

Parent’s E-Mail: ________________________

à Would you like to help with Southbridge Soccer? Yes= / No (circle one) How? ___________________

Comments: ______________________________________________________________________=

Ab= ide by Rules, Release, and Consent for medical treatment (minor):

I, the parent/guardian of the registrant, a minor, agree that I and the regist= rant will abide by the rules of Mass Youth Soccer, US Youth Soccer, Southbridge Youth Soccer Association and their affiliates. Recognizing the possibility = of physical injury associated with soccer and in consideration for Mass Youth Soccer/US Youth Soccer accepting the registrant for its soccer programs and activities (the “programs”), I hereby release, discharge and or otherwise indemnify Mass Youth Soccer/US Youth Soccer, Southbridge Youth So= ccer Association, sponsors and affiliates, their employees and personnel, includ= ing owners of fields and facilities utilized for the Programs, against any clai= m by or on the behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which is transportation I hereby authorize.

As parent or legal guardian of the above named player, I hereby give my consent for emergency medical care prescribe= d by a duly licensed Doctor of medicine or Doctor of dentistry. This care may be given under whate= ver conditions are necessary to preserve life, limb, or well being of my depend= ent.

Paren= t or Guardian Name: __________________________________

Parent or Guardian Signature: _______________________________ Date: _______= ___

Fees: Families, discount $5 for addition= al sibling(s) &= nbsp; &nbs= p; &= nbsp; Check out our Website=

àIn-Town Program: $40.00 (U-6, U-8) &nb= sp; = www.southbridgesoccer.org=

see web site for age limitations and proper classification(s) &= nbsp; &nbs= p; &= nbsp;

àTraveling Program: $70.00 (U-10, U-12, U-14, U-16) &= nbsp; Mail form and fee to:

(Add uniform fee of $30.00 for first time travel players ) &= nbsp; Southbridge Youth Soccer

&nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;            =        PO Box 276
Early registration Discount:  &nb= sp;            =             &nb= sp;            =             &nb= sp;       Southbridge, MA 01550
Ded= uct $5.00 for early registration (postmarked before
Mar 1 for spring session or Aug 1 for fall).   &nb= sp;            =             &nb= sp;            =             &nb= sp;            =             &nb= sp;

Registration cut-off dates: &= nbsp; &nbs= p; &= nbsp; &nbs= p; =

Spring Season: March 16=

Fall Season: August 16 &= nbsp; &nbs= p; &= nbsp; &nbs= p;

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S.Y.S.A use only: &= nbsp; &= nbsp; &nbs= p; &= nbsp; &nbs= p; = &nb= sp; = =

Amount paid with this application: = &nb= sp; = &nb= sp; = &nb= sp; =

$______ Cash / Check Rec. by: ____