NEWTON YOUTH SOCCER

PO BOX 610308 - NEWTON, MA 02461

BAYS TRAVEL PROGRAM  REGISTRATION

(please print this form for paper registration)

Parent/Guardian:  Please COMPLETE this form and return  with your check made payable to NYS in the amount of $90.00. A $15.00 late fee will be assessed for any payment postmarked after the deadline date. If there is a problem with the fee, please contact us.  If we do not have your birth certificate on file, please provide a photocopy with this form.

Player's Name: __________________________________Birthdate: ________________ Sex: _________

                                                    First name Last name

Address: ____________________________________________________ Zip code: _______________

Home Phone: _____________________ Email: ______________________________________________

Grade: _____ School: _____________________________ Birth Cert. on file?: _____________________

Public Elementary School District: __________________Parent: ________________________________                                                                                                                       Parent: _______________________________

Work Phone: _________________________________ Work Phone: _____________________________

Age Group: ________________________________ Coach: ____________________________________

BAYS Team: _______________________________

In Case of Person to Contact: ________________________ Phone Number: __________________

Emergency: Doctor to Notify: __________________________ Phone Number: __________________

Medical Insurance Carrier: _______________________________  

RELEASE

I, the parent/guardian of the person named on this form, a minor, agree that I and the registrant will abide by the rules of the United States Youth Soccer Association (USYSA), Massachusetts Youth Soccer Association (MYSA), Boston Area Youth Soccer (BAYS), Newton Youth Soccer (NYS), their affiliated organizations and sponsors. I desire to have the registrant participate in the soccer programs and activities, whether they are indoors, or outside, and including practices and clinics ("Programs"), offered by or in connection with the USYSA, MYSA, BAYS, NYS, and /or their affiliated organizations and sponsors. I recognize that the registrant may suffer physical injury as a result or the registrant's participation in the Programs. Accordingly, in consideration for and as an inducement to USYSA, MYSA, BAYS, and NYS accepting the registrant for participation in the Programs, on behalf of myself and the registrant I, hereby release, discharge, hold harmless and indemnify USYSA, MYSA, BAYS, NYS, their affiliated organizations and sponsors and respective officers, directors, employees, coaches, committees and associated personnel, including, without limitation, the owners of the fields and facilities utilized for the Programs, of and from any claims, demands, actions, causes of action, suits and liability arising as a result of the registrant's participation in the Programs including, without limitation, the transport of the registrant to or from the Programs, which transportation I hereby authorize.

CONSENT FOR MEDICAL TREATMENT OF A MINOR

As parent or legal guardian of the minor named on this form I give my consent to seek, obtain, and provide emergency medical treatment for such minor in case of injury that occurs while participating in Newton Youth Soccer-related activities. This care may be given under whatever conditions are necessary to preserve life, limb, or well-being of such minor. I understand that such treatment will be sought and provided only in an emergency and that reasonable efforts will be made to contact me before providing such treatment.

Signature of Parent/Guardian for Release and Consent:_________________________________________________

Date:___________________________

TO THE PARENT OR GUARDIAN: You are not required to provide the following information. This information will be useful if your child requires emergency medical treatment.

Date of last tetanus shot__________________________________ Other allergies:_____________________________________

Allergies to medications:__________________________________ Present medications:_________________________________

Parent Willing to help:_____________________________________Check here if financial assistance is needed:_______________

(need parents to volunteer as coaches, asst coaches, managers, etc.)

Scholarship: The Greg Chan and Steve Glidden Scholarship Fund: Greg and Steve met on a Newton Soccer Field. Their enthusiasm and friendship remind us all of what is most important. Greg and Steve passed away together on a school trip on April 27, 2001. In their honor NYS has established a scholarship fund to enable children with financial need to participate in our programs.

I'd like to contribute to this fund: ___$25 ___ $35 ___ $50 ___0ther