YALE-BROCKWAY SOCCER REGISTRATION

Athlete Name: *

Season: *
Select a Season Spring Fall

Address: *

City/Twp: *

Zip: *

Can we text message you? *
Yes   No

Parent/Guardian 1: *

Parent/Guardian 1's Phone: *

Phone Type: *
Home   Work   Cell

Parent/Guardian 2: *

Parent/Guardian 2's Phone: *

Phone Type: *
Home   Work   Cell

Shirt Size: *
Select a Size X-Small (2-4) Small (6-8) Medium (10-12) Large (14-16) Small Medium Large X-Large

MEDICAL INFORMATION:

Any Known Allergies: *

Present Medications and Illnesses: *

Gender: *
Male   Female

Grade: *

Height: *

Birthday: *

Age as of April 1^st for Spring Soccer: *

Age as of August 1^st for Fall Soccer: *

I would like to coach: *
Yes   No

I would like to sponsor a team: *
Yes   No

Registration Fee:           $45 first child     $40 second child     $35 third child     $25 forth child

Siblings Name if on same team: *

RELEASE OF INJURY/MEDICAL INFORMATION:

NAME OF INSURANCE: *

SUBSCRIBER NAME AND NUMBER: *

REGISTRATION FORM AND MONEY WILL ONLY BE ACCEPTED DURING REGISTRATION. This release gives permission to the Yale-Brockway Recreation Staff to administer first aid to your child in the absence of a parent or guardian. Your signature gives permission to give your child care at the nearest hospital by ambulance, if necessary. I hereby waive all claims that I may have against the City of Yale, Brockway Township and the Yale-Brockway Recreation Council, directors or coaches arising out of any injury my child may sustain while participating in this league. I agree to abide by all of the rules and regulations of the Yale-Brockway Recreation Council and leagues. I also understand there is NO SMOKING within 100 yards of any playing field.

Yale-Brockway Recreation will follow the Health Department's Guidelines for COVID-19 for Soccer.

Parent/Guardian Signature: *

Payment Method: *
Select a Method Cash Check

Receipt Number:

Amount Paid:

Received By:

Payment Date:

Payment Time: