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DAYAA Derry Soccer and Lady Trojans Registration Summer 2015
Girls Youth Soccer ages 8-12
Last Day for Registration by Mail June 20th, 2015
Practices/games:
Tuesday and Thursday 6-8 PM
Family Name_____________________________________________ Parent/Guardian First Name____________________________________________
Address____________________________________________________________ City________________________________ Zip________________
Home Phone_____________________________________ Cell Phone__________________________________________ Text Yes _____ No______
Email____________________________________________________________________@________________________________________________
One Player $35
Age
Player
Birthdate
Shirt*
1.__________________________________________
_____
_________________
______
2. __________________________________________
_____
_________________
______
3. _________________________________________ _
_____
_________________
______
4. __________________________________________
_____
_________________
______
*Please indicate Adult (A) or Youth (Y) size for shirt
Shirt Sizes
S
M
L
XL
Women (A)
6/8
10/12 14/16 18/20
Youth (Y)
4/5
6/8
10/12 14/16
XXL
22/24
Additional Players may be listed on the back.
Deadline for mail in Registration is June 20th, 2015**
Liability/Release Waiver
I permit my son/daughter to participate in Derry Soccer. I understand that it is my responsibility to provide transportation to and
from practices and games. I hold harmless DAYAA Derry Soccer, its Board members and Officers, Mrs. Gregory H. Paskovitch,
and any agent working or volunteering for DAYAA Derry Soccer in any foreseen or unforeseen acts. I permit DAYAA Derry Soccer
to use any pictures taken during the season of my child on their website for advertising purposes. Any refunds after jerseys have
been ordered will be subject to a $20.00 processing fee per jersey. Smoking on the field is prohibited.
Parent/Guardian Signature _X_____________________________________________________ Date __________________________
Registration Fee $____________ Check #_________
Please mail form along with payment, to;
DAYAA Derry Soccer
PO Box 272
New Derry, PA 15671
**For more information visit us on the web at www. derrysoccer-pa.com or like us on Facebook: Derry Soccer