Van Buren Youth Soccer Association

USYSA Membership Form

Youth Division of the United States Soccer Federation (USSF)

Affiliated with the Federation Internationale de Football Association (FIFA)

Please write legibly and fill out the form completely.

Last

First

Mid

Name:

Name:

Initial:

Address:

City:

Zip:

Telephone:

Birthdate:

/

Male

Female

E-Mail Address

Child's Mother's Birthdate:

(MM/DD)

REQUIRED (no year)

Guardian's Name (M):

Phone:

Guardian's Name (F):

Phone:

Address (if different):

Any Medical Problem or Prohibition Player has:

Person to Notify in Emergency:

Phone:

Doctor to Notify in Emergency:

Phone:

School

Grade

New Player to VBYSA:

Played for Van Buren Youth Soccer before on (Team Name):

As a player, I agree to conduct myself in a manner which exhibits good sportsmanship at all games, including tournament.  This includes showing respect, through proper behavior

and language, towards players, coaches, referees and spectators.  I understand that any behavior on my part that is offensive, threatening, or disrespectful, may result in my immediate

dismissal from the game area, and/or displinary action.  Please note that coaches reserve the right to limits a player's actual playing time on the field for displine purposes.

Player Signature:

Jersey Size U-6 ONLY

Jersey Size U-8 to U-19

Youth Small (6-8)

Youth Large (14-16)

Youth Medium (10-12)

Adult Medium

Youth Medium (10-12)

Youth Large (14-16)

Adult Large

Adult Small

Adult X-Large

Jersey Agreement

The team Jersey received by your son/daughter is the property of Van Buren Youth Soccer Association.  It is to be returned in a clean and wearable

condition at the end of the soccer season.  Failure to return the game jersey will result in a $50.00 fee being assessed to you to replace it.

The Jersey is to be worn to games and pictures only. No practices or school.

Consent for Medical Treatment (Minor)

As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care 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.

Rules of the USYSA

I, the parent/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 "Program"), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors (e.g. The Black

Swamp Soccer League, Van Buren Youth Soccer Association and coaches, Allen Township Trustees and the Van Buren Sports Community Association),

their employees and associated personnel, including owners of 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/from the same, which transportation I hereby authorize.

Parental/Guardian Support

We ask for active participation (at least 1 hour per family) in our Program.  Check area(s) in which you would be willing to help.  If you do not wish to

participate by volunteering, you will be charged a $75 deferral fee.  The deferral fee is due at registration.

Coach (           )

Asst Coach (               )

Team Parent

Field Tear Down

Concession Worker

Paint Fields

Jersey Coord.

Field Set Up

Fall Tournament Concession Coord.

I DO NOT WISH TO VOLUNTEER AND HAVE INCLUDED THE $75 DEFERRAL FEE WITH REGISTRATION

Please sign here to indicate you've read and agree to the above.

Name:

Signature:

Date:

Parent/Legal Guardian (please print)

Registrar Use:

Date:

CK#

Cash:

Div: