Merritt Youth Soccer 2015 Registration Form For youth who are between the ages of 4 (Born 2011) and 16 (Born 1999) Name: Parent/Guardian Name Home Address/Mailing Address Birthdate m/d/year Gender Home Telephone Work Phone Number Cell Phone Number Care Card Number Medical Conditions we should be aware of: M____ F____ Email Address Name Registration: Emergency Contact Other Than Parent/Guardian Home Phone # Cell Phone # Work Phone # Early Bird Fee until January 31, 2015 $80.00 Regular Fees start February 1, 2015 $110.00 Closes March 13, 2015 Late Registrations will only be accepted depending on space availability and the Fee will be $140.00 NOTE: Registration includes soccer jersey, soccer socks, and soccer shorts to keep I am interested in coaching/assistant coaching: Yes ______ No______ NOTE: COACHING CLINICS WILL BE PROVIDED If YES – please provide your contact info if it differs from your child: _____________________ ______________________________________________________________________________ MYSA will no longer be accepting special requests. I hereby consent to the above named player to participate in activities of the Merritt Youth Soccer Association and release Merritt Youth Soccer Association and its volunteers from any liability that may occur during these sessions. Signature: ____________________ Date: ______________________ Refund Enquiry: Please contact MYSA at [email protected] and a representative will get back to you. Please mail this registration form, along with a cheque made out to t Merritt Youth Soccer Association to: MYSA, PO Box 1868, Merritt BC, V1K 1B8 ADMIN USE ONLY - BC#:________________ Parental Liability Acknowledgement Form I, acknowledge the registration of my child, (Name of Parent/Guardian) (Name of Player) who has not reached the age of majority (19), in an Adult (Senior) League sanctioned by BC Soccer. I further acknowledge that my child has signed a release on his or her player registration and insurance application form which states, in part: I the applicant, on behalf of myself, members of my family, my heirs, executors, administrators and assignees, hereby forever release, discharge and hold harmless BC Soccer and their representatives and agents for any injury, loss or damage to my person or property howsoever caused, arising out of or in connection with my taking part in soccer activities and not withstanding that the same may have been contributed to or occasioned by the negligence or BC Soccer or their representatives or agents. Youth aged players who register in an Adult (Senior) League are not eligible to play for a youth aged club team in this or any subsequent playing seasons unless reinstated as a youth player. Parent/Guardian Signature: Date(dd/mm/yyyy):