Southeastern Stokes Youth Soccer Association

Fall 2003 Sign-ups

Registration fee: $50 ($45 for each additional child)

Registration Deadline is June 28 � NO LATE ENTRIES ACCEPTED; ANY REC�D AFTER DEADLINE WILL BE PUT ON A WAITING LIST!!

NO REFUNDS!!!

WE DO NOT GUARANTEE ANY SPECIAL REQUESTS FOR SPECIFIC TEAMS/COACHES!

Mail completed registration form to:�� SSYSA

��������������������� ��������������������� �������������� �� 1055 Hilltop Drive

��������������������� ��������������������� �������������� �� Germanton, NC 27019

F Name: ___________��� MI: ___� L Name:������ ________________���� SS #:� _____________________

Male:� ____� Female:� _____������ Birthdate:� ________________����� No. of Yrs. Played____________

Address:� ____________________________________________________________________________

Mother�s Name:� ____________________� Mother�s Work/Cel Phone:� ________________________

Father�s Name:� ____________________�� Father�s Work/Cel Phone:��� ________________________

Email Address:� ______________________________________________________________________

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.�

PARENT SIGNATURE:___________________________________������ (REQUIRED!!!)

I am interested in being a coach_____, asst. coach ______, team parent ________.

For SSYSA Use Only:

Cash ____ or Check __________Total Paid: ___________

Date Paid:� ______________������� Rec�d by: ________________________


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