Player Information
Last Name: First Name: MI:
Address:    
City:                      State:          Zip:
Phone Number:        Birth date (mm/dd/yyyy):      Gender: Male Female
Contact E-mail Address:

Parent / Guardian Information
Father / Legal Guardian's Name: Mother's Name:
In  case  of  emergency,  notify:          Phone:       
List any medical problem or prohibition player has:


REGISTRATION STATEMENT: By entering my full name and contact information and submitting this electronic form, I, the parent or 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/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the 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. I agree that my submission of this electronic form, together with my payment of associated registration fees, constitutes by acceptance of this statement.


CONSENT FOR MEDICAL TREATMENT (MINOR) By entering my full name and contact information and submitting this electronic form, I give the following consent:  As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care as prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry.  This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent.
Parent or Guardian's Full Name:
Address: 
City: State: Zip:  
Home Phone: Alternate Phone: