Southeastern Stokes Youth Soccer Association
Registration Form

Registration fee: $50 ($45 for each additional child)   NO REFUNDS!!!

WE DO NOT GUARANTEE ANY SPECIAL REQUESTS FOR SPECIFIC TEAMS/COACHES!
Mail completed registration form to:   SSYSA   P.O. Box 1185   Walnut Cove, NC   27052

F Name: __________________  L Name:______________________    SS #:_____________________
Male:____ Female:____  Birthdate: Month:_____ Day:____ Year: 19____  No. of Yrs. Played___
Street Address: _____________________________ City: _____________________ Zip:________
Mother�s Name: _______________________ Mother�s Work Cell Phone: _____________________
Father�s Name: ________________________Father�s Work Cell Phone: ______________________
Email Address: ______________________________________    Home Phone:_________________

NAME AS IT SHOULD APPEAR ON TROPHY: _______________________________________

Special Needs: ____________________________________________________________________

Uniform Size:              
 
Youth
Adult
Shirt Size (Circle ONE only!!):
YS
YM
YL
  
AS
AM
AL
Short Size (Circle ONE only!!):
YS
YM
YL
  
AS
AM
AL

PLEASE READ & SIGN BELOW � PLAYERS ARE NOT ALLOWED TO PRACTICE UNTIL THIS FORM IS SIGNED & SUBMITTED TO SSYSA!!!
Having been informed of the organization of Southeastern Stokes Youth Soccer Association (SSYSA) to provide supported soccer games for the children, I/we the parents of the so named candidate do hereby give my/our approval to his/her participation in any and all activities. I/we understand the nature of the insurance coverage provided through the registration fee. However, I/we do assume all additional responsibility for hazards incurred in the conduct of the activities, transportation to and from activities, and I/we do further hereby release, absolve, indemnify, and hold harmless the SSYSA, and also the others listed hereafter: Organizers, Officers, Sponsors, Landowners permitting use of their land for soccer activities: any and all of them. I/we also agree to furnish a birth certificate if requested by SSYSA. In case of injury to my/our child, I/we waive all claims against the organizers, sponsors, coaches or referees appointed by them. Additionally, I/we give permission for our child�s first name and last initial to be published on the SSYSA website along with a photo of the child taken during team play, formal team photo, or award recognition ceremony.

PARENT SIGNATURE:_______________________________________________(REQUIRED!!!)
I am interested in being a coach_____, asst. coach ______, team parent ________.


For SSYSA Use Only:
Cash _____ or Check ______ Total Paid: ___________ Birth Certificate Reviewed:Y / N
Date Paid:_____________ Rec�d by: __________________ Reviewed by: ___________________


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