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MARIETTA SOCCER LEAGUE REGISTRATION
P.O. Box 405 Marietta OH 45750
YEAR 2009/10 FALL $35.OO SPRING $35.00 BOTH $60.00
Age Division Circle One Under-6 Under 8 Under 10 Under12 Under 14 (8/1/03-7/31/05) (8/1/01-7/31//03) (8/1/99-7/31/01) (8/1/97-7/31/99) (8/1/95-7/31/97)
Payment _______Check # ______________ Cash $ _______________ 1 child of ______________ _____________________________________________________________________________________
LAST NAME FIRST NAME INITIAL
_____________________________________________________________________________________ ADDRESS CITY STATE/ZIP _____________________________________________________________________________________ HOME PHONE /BEST TIME TO CALL BIRTHDATE MALE FEMALE _____________________________________________________ FATHER'S NAME WORK PHONE ________________________________ _____________________________________________________ E-MAIL ADDRESS MOTHER'S NAME WORK PHONE (for up to date league info) _____________________________________________________________________________________ MEDICAL PROBLEMS OR PROHIBITIONS/ALLERGIES _____________________________________________________________________________________ IN CASE OF EMERGENCY PLEASE NOTIFY IF DIFFERENT THEN ABOVE PHONE _____________________________________________________________________________________ DOCTOR TO NOTIFY IN EMERGENCY PHONE CIRCLE TO VOLUNTEER Coach / Assistant / Fields / Concessions / Board / Tournament Committee CIRCLE SHIRT SIZE M(10-12) L(14-16) Adult S M L XL Have you ever played organized soccer before ? YES NO How many years ? _________ CONSENT I, the Residential Parent/Legal Guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of USYSA, its affiliated organizations and sponsors, Recognizing the possibility of physical injury associated with discharge and/or otherwise indemnity the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the program, against any claim by or on behalf of the registrant as a result of the registrant's participation in the program and /or being transported to or from the same, which transportation I hereby authorize. As the Residential Parent/Legal Guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent. Signature__________________________________ Date______________ |
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