Chamberlain Soccer

2009 Fall Season Registration

Fee: $25.00 per player (one player per form, please)

        $15.00 late fee per family starting September 1

Make checks payable to: COAST

AGE:       U5       U6       U8       U10     U12B      U12G      U14 Co-ed     (Circle one – see age division on back)

                  (First year players in U8 and above must furnish a state certified copy of their birth certificate.)

Last Name __________________________   First Name ____________________________       MI _______

Address _________________________________   City ____________________________        State ______

Zip ________     Phone  ____________________      Sex:       M     F            School ______________________

Current Age _________________          Birth Date ________________        Grade _______________________

Dad’s Last Name   _______________________    First Name  __________________    Phone _____________

Email Address        _______________________________________

Mom’s Last Name ______________________     First Name  __________________    Phone _____________

Volunteers are needed. Please check where you can help our organization:

_____ Concessions   _____ Coach    _____ Referee  _____ Board Member    _____ Assistant Coach

Signature required before child can play. Please read the following and sign below.

Consent for Medical Treatment of Minor

As the Parent/Legal Guardian of the above named minor child, I hereby give my consent for Emergency Medical Care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions necessary to preserve life, limb or the well-being of my dependent.

Agreement to Abide and Hold Harmless

As the parent/guardian of the registrant, a minor, I 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 for the Programs, against any claim on behalf of the registration 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.

Signature of Parent/Legal Guardian  ____________________________________________      Date _________________

For office use only

$ Paid _________Check # _________   Received by ________    Date Received ______________          ______ of _____

Age Group Matrix for 2009/2010 Season

Except for U5, if your child is in an odd age group, they will play in the next even group.

BUILDING CHARACTER THROUGH YOUTH SOCCER

CHAMBERLAIN SOCCER CLUB