MAUMEE YOUTH SOCCER REGISTRATION FORM

MAUMEE YOUTH SOCCER CAMP WEB REGISTRATION FORM

MAUMEE YOUTH SOCCER REGISTRATION
PO BOX 489 Maumee, Ohio 43537

Please Print & Sign Three Copies

COMPLETE ALL SECTIONS FROM HERE DOWN

Last Name ___________________________ First Name _____________________________ Middle Initial _______ Sex ________

Address ________________________________________________________________ City __________________________________________

State ____________ Zip Code _______________ Phone ( ) ______________________________ Birthdate ______ / ______ / ______

Social Security # _________ _______ _________ School __________________________________________________________

Grade _______ (grade child will be in next fall - limited to grades 1 thru 6)

Father's Name _____________________________________ Occupation _____________________ Business Phone ___________________

Mother's Name _____________________________________ Occupation _____________________ Business Phone ___________________

List any medical problems or prohibition player has __________________________________________________________________________

Person to notify other than parents, in case of emergency _________________________________________ Phone ____________________

Doctor to notify in case of emergency ___________________________________________________________ Phone _____________________

I the parent / guardian of the registrant, a minor, agree that I and the registrant 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 programs and activities (the "Programs"). I hereby release discharge and otherwise indemnify the USYSA, Its affilited organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilied 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.

Name ______________________________________________________
Parent/Legal Guardian
Signature ____________________________ Date ____ / ____ / ____

CONSENT FOR MEDICAL TREATMENT
As a parent or legal guardian of the above-named player, I hereby give my concent for emergency medical care prescribed by a dully licensed Doctor of medicine or Doctor of Denistry. This care may be given under whatever conditions are nescessary to preserve the life, limb or well-being of my dependent.

Signature ___________________________ Date ____ / _____ / _____
Address ____________________________________________________
City ____________________ State ______ Zip Code __________
Phone _______________________ ________________________
Home Business

COMPLETE THIS BLOCK TO DETERMINE FEE OWED
A. Registration Fee	$50.00
B. Outside Maumee School District add	$ 0.00
C. Late Fee (add if applicable)	$10.00

Total Enclosed	$ ________

Please Print and Mail 3 copies to;
MYSA
PO Box 489
Maumee, Ohio 43537
Registration fees are non-refundable

Late fees apply after June 14, 2006