PO Box 186
Cairo, NY  12413

Player's Last Name:                                                            First Name:
Street:                                        Town:                                 State:                                     Zip:
Home Phone#:                                         Cell Phone #                                E-mail:

Sex:                      Age:               D/0/B:                     Shirt Size: __YS __YM __YL __ AS __AM __ AL      

Father's  Last Name:                                                   First Name:
Home Phone#:   
__Yes, I can Volunteer:   __Coach  __Assist. Coach  __Referee  __Other

Mother's  Last Name:                                                 First Name:
Home Phone#:               
__Yes, I can Volunteer:   __Coach  __Assist. Coach  __Referee  __Other

__Yes, I would like to sponsor a team:  COMPANY NAME:                                   Phone #

Medical Conditions/Allergies:
Emergency Contact Person, other than parent:

Doctor:                                                                                                   Phone#:
Medical Insurance Co.:

Consent for Medical Treatment
As the parent or legal guardian of the above named player, I hereby give my 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.

Signature of Parent/Gaurdian:

I, the parent/guardian of the registrant, a minor, agree that the registrant and I 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 "Programs"), I hereby release, discharge and/or otherwise indemnify the USYSA, 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.

Signature of Parent/Guardian:
Registration Fees:  Travel U12 $70.00 U14   $75.00  U16 $80.00 and U17 $85.00  
Summer $35.00        Fall   $35.00  ( 2nd child $30.00, 3rd child $20.00 for recreation only)

CASH:_________                                                                        AMOUNT PAID:__________________
CHECK#:___________                                                                 TEAM UNDER:_________
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