2010_Fall_Reg by ashrafp


									   Spring                                       AGAWAM SOCCER ASSOCIATION
        Fall                                                REGISTRATION FORM
     In –Town Rec. League                       OR           Pioneer Valley Travel Team                             Male            Female

Player Name:                                                                        Date of Birth:                    /             /
Address:                                                                            City:                                         State: MA Zip:
Home Phone #:                       -            -                                  Parent’s Cell Phone #:                           -          -
E-Mail Address:
                                                                                                            GRADE                         AGE GROUP
 Uniform Size:                                                                                      Grade during the soccer
 Please specify youth or adult sizing.                                                                     season

Has your child played soccer before?                         Yes         No
Has your child played goalie before?                         Yes         No
If yes, what age group:                                                                                                                  Do not write in
                                                                                                                                         this box, ASA
Last season coach or
                                                                                                                                           staff only
team name or color:

                                        REGISTRATION FEES:
                                                                                                                                  Received by:
 Pre-K                                               $75
 Kindergarten                                        $75
 In-Town U-7 & Above                                 $85                                                                      Cash or Check #:
 Pioneer Valley Travel Team                          $115
                                                                                     Amount Paid
                                                                                                                               To be filled out by ASA Staff
 Please makes checks payable to:                     AGAWAM SOCCER ASSOCIATION
MEDICAL INFORMATION AND WAIVER OF INJURY: (Please include name & phone # when possible)
Medical Problems:
Person to Notify in Emergency:                                                                       Cell Phone #:                   -      -

  I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the USYSA, its affiliated organizations and
  sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer
  program and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their
  employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on the 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.
  I also understand that an injury to my child in league practice or during a game is my responsibility and that the Town of Agawam Park and Recreation
  Department, whose facilities are used, and the Agawam Soccer Association, and its coaches and members, are hereby released from liability.

  Consent for Medical Treatment (minor)
  As Parent or legal guardian of the above-named player, I hereby give my consent for emergency medical care prescribed by a duly licensed
  Doctor or 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:                                                               Parent’s Name:

  Address:                                                                 City:                                     State:                     Zip:

  Home Phone #:                 -           -                              Business Phone #:                -             -

  Cell Phone #:             -           -                                  Today’s Date:              /         /

         I would like to help:                  COACH        ASST. COACH               RIVERSIDE TOURNAMENT                              JAMBOREE

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