CONNETQUOT YOUTH SOCCER LEAGUE

P.O. BOX 1136, RONKONKOMA, NY 11779
(631) 588-6283

________________________                _________________________                         ______________________
    PLAYERS LAST NAME                               FIRST NAME                                             TELEPHONE
 
 

___________           _________________________________     _____________________________     _____________
 HOUSE#                         STREET NAME                                             TOWN                             ZIP CODE
 
 

____________________             __________________________                             ___________________
   TEAM NAME                              PLAYERS BIRTH DATE                                            DIVISION

I HEREBY GIVE MY CONSENT FOR ALL MEDICAL CARE PRESCRIBED BY A DULY LICENSED DOCTOR OF MEDICINE FOR THE MINOR NAMED ABOVE AS HIS/HER LEGAL GUARDIAN. THIS CARE MAY BE GIVEN UNDER WHATEVER CONDITIONS ARE NECESSARY TO PRESERVE THE LIFE, LIMB OR WELL BEING OF MY DEPENDENT. PARENTS OF SPECIAL CHILDREN, PLEASE ADVISE THE LEAGUE. THIS INFORMATION WILL ASSIST THE COACH IN HANDLING OCCURANCES SHOULD THEY ARISE. I/WE DO HEREBY WAIVE, RELEASE, ABSOLVE THE ORGANIZERS, SPONSORS, SUPERVISORS, COACHES, PARTICIPANTS AND THE CONNETQUOT YOUTH SOCCER LEAGUE AS A WHOLE FROM ANY CLAIMS ARISING OUT OF INJURY OR ANY OTHER OCCURANCES TO MY SON/DAUGHTER EXCEPT TO THE EXTENT IN AN AMOUNT COVERED BY ACCIDENT OR LIABILITY INSURANCE WITH A COPY OF THE SUMMARY COVERAGE.

# OF YEARS PLAYED:__________ GRADE:________
 

I WOULD LIKE TO BE A:     VOLUNTEER_____        COACH_____         ASSISTANT_____          TEAM PARENT_____

PAYMENT:          ____________ONE SEASON            ____________UNIFORM AMOUNT
                       $35.00/$45.00 (Interleague)        $35.00/$45.00 (Interleague)

DATE:_____________         SIGNATURE__________________________________         CHECK #_____________