Yorkton Soccer

Online Registration Form
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Player Information			* Required fields ______________________ YSA will need to issue a receipt for tax purposes.

Last Name*
First Name*
Address*
City*
Postal Code*
Email
Parent's Name

Mother
Father
Phone Numbers

Home Phone*
Mother's Work
Father's Work

I Can Volunteer To:
Coach	Committee
Co-Coach	Mini-Festival


Player Information

Gender
Birth Date	Day Month Year
Hosp#

Player Medical Information

Contacts in Case of Emergency:
Name 1
Phone 1
Name 2
Phone 2

Family Doctor
Name
Phone

Medications
Allergies
Does the player carry and know how to administer his/her own medecine:			Yes No

Other: (braces, contact lenses, previous injuries, etc)


Release and Consent For Medical Treatment: (READ)

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the YSA, it's affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the YSA accepting the registrant for it's soccer programs and activities ("the Programs"), I hereby release, discharge and/or otherwise indemnify the YSA, it's affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs and/or being transported to or from the same. which transportation i hereby authorize. 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 Medecine or Doctor in Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.

Yes, I accept the release consent for medical treatment


The following information is used to assist in team selection. All players will be subject to team trades as deemed necessary by YSA based on an assessment of team fairness after two weeks of regular scheduled season play.
Soccer Experience

Years Played
Recreational		Indoor		Outdoor
Competitive		Indoor		Outdoor


Fees Make cheque payable to: YSA or Yorkton Soccer Association (All NSF Cheques will be charged $20) YSA will need to issue a receipt for tax purposes. Outdoor 2010 Fees - $100 Be sure to add email so we can contact you to acknowledge receipt of the registration