2007 Registration Marshfield Youth Soccer Association (MYSA)

Player Information: Returning Player: Yes / No If Yes, 2006 Team ________________ Uniform # ______

Last Name: _________________________First Name: ____________________________________________________

Address:__________________________________________________________________________________________

City: ______________________________ WI Zip____________________ Phone: ______________________________

Date of Birth: _______/_______/_______ Gender: M / F Parent Email Address: ______________________________

Parent/Legal Guardian Information:

Father’s Name: _________________________________Mother’s Name: ______________________________________

Phone # (Home/Work) ___________________________Phone # (Home/Work) _________________________________

Consent of Medical Treatment for Minor & Liability Waiver:

Medical problems, allergies or medications ______________________________________________________________

(Use the back of registration form for any specific directions regarding health)

Doctor: _____________________________________________________Phone: _______________________________

I, the parent/legal guardian of the above named player, 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/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 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 transportation I hereby authorize.

As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry, or other medically qualified emergency medical personnel. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my dependent.

If parents choose NOT to have their child’s picture or name in the newspaper and/or webpages, they need to complete a Media Nonparticipation Request Form available from the Club President.

I have read and fully understand the above statements.

Parent / Guardian Signature:_________________________________________________Date:___________________

Registration Fees: $60 – U10

$100-U11-U18 ($75 registration fee + $25 tournament fee)

Note: All teams U11 and up will play in a minimum of 1 tournament.

*Uniform Cost ($75): This will be collected when uniform is ordered. Uniform kit includes 2 jerseys, shorts, 2 pair of socks.

Please make registration check payable to Marshfield Youth Soccer Association or M Y S A.

Check # Enclosed: __________Amount: $_________ Number of registrations paid with this check: _______

Checklist: _____ Parent/Guardian Signature

______$60 registration U10 or $100 registration fee U11 and up.

______Headshot photo (max. 1 1/2" x 1 1/2") for player ID card

______Copy of birth certificate, new registrations only

**No player will be considered registered and allowed to play until the fee is paid and all paperwork is in order.

_______I would like to be considered for financial assistance.

Send completed registration forms, checks, pictures and birth certificates to:

Jana Wagner, MYSA Registrar

11597 Stadt Rd.

Marshfield, WI 54449