Form

First Name*

Middle Initial

Last Name*

Address*

City*

State*

Zip*

Phone*

Birth Date*

Month Day Year

First-time Registrants: Upload a copy of your Birth Certificate

Parent 1 Name*

Parent 1 Day Phone*

Parent 1 Eve Phone*

Parent 2 Name

Parent 2 Day Phone

Parent 2 Eve Phone

Email Address*

Cell #'s

Person to notify in emergency*

MEDICAL INFORMATION & CONSENT

Doctor*

Clinic*

Clinic Phone*

Hospital*

Medical Insurance*

Dentist*

Dental Insurance*

Dentist Phone*

MEDICAL RELEASE: As the parent or legal guardian of a participant in the USYA/MYSA/AYSA/NYSA programs, I give consent for emergency medical care by a duly licensed Doctor of Medicine or Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well-being of my dependent.

AGREEMENT: I, the parent/guardian of the registrant, a minor,agree that the registrant and I will abide by the rules of the United States Youth Soccer Association (USYSA), the Minnesota Youth Soccer Association ( MYSA), the Arrowhead Youth Soccer Association (AYSA), Northwood Youth Soccer Association (NYSA), and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA,MYSA,AYSA,NYSA,accepting the registrant for its soccer programs and activities, I hereby release, discharge, and/or otherwise indemnify the USYA,MYSA,AYSA,NYSA, and its affiliated organizations, and sponsors, their employees and associated personnel, including the 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 or from the same, which transportation I hereby authorize.

Parent/Legal Guardian Name*

Registrant Name*

Parent/Guardian Initials*

Registrant Initials*

Today's Date

- Month - Day Year

at

/ Hour Minutes

PARENT OPPORTUNITIES: We are asking for active participation in the program. Please select the area(s) you are willing to help with.

Area to help

Payment will be collected via PayPal in the next step. Click "SUBMIT REGISTRATION" to continue.