MYSA/USYSA

Also registered with (Enter Date/Season):

Dighton Recreational Soccer

Rehoboth Recreational Soccer

MAPLE

LASA

Membership Form

CHECKS  $85.00 made out to DRSC

CK #

DRSC Use

Date Received

1

Dighton-Rehoboth Soccer Club (STRIKERS)

Organization Name

P

C

R

A

FEE -- Circle Player (P)

NO FEE -- Coach (C), Referee (R), Administrator (A)

License Level

License Date

CORI KidSafe (Y/N)

2

Last Name

First Name

Street

City

State

Zip

Birthday          School Grade

Male / Female

Email Address                                                               Home Phone

Players Father's Name

Occupation

Business Phone

Player Mother's Name

Occupation

Business Phone

Medical Problems?

Person to Notify in Emergency

Phone   

Doctor to Notify in Emergency

Phone    

3

4

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 “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 the behalf of the registrant as a result of the registrant’s

Consent for Medical Treatment (Minor)

As 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 life, limb, or well-being of my dependent.

Name

Name

Signature

Signature

Home Phone

Doctor’s Name

Business Phone

Doctor’s Phone

Cell Phone

Would a parent like to help with the team or possibly coach?