Barrington Youth Soccer Assoc. (RI)

Barrington Youth Soccer e-Registration System

Fall 2009 House League Registration

Program Fee: $80.00 + Field Use Fee: $10.00 = Total Registration Fee: $90.00

Program Fee: $80.00 each for first 2 players from same family; $50.00 each additional player.
Field Use Fee: $10.00 per player = Total Registration Fee $90.00 for first 2 players; $60.00 each additional player.
Note: The players must all be registered at the same time.

If you register after 7/31/2009, a $20.00 late fee will be added; late registrations are not guaranteed a roster spot.

Personal Information:

First Name	Last Name

Date of Birth(format 02/23/1997)
Month / Day / Year

Street Address	Apt#

City, State, Zip

Gender
Boy Girl

Home Phone
( ) - -

Mother's First Name	Mother's Last Name

Mother's Cell Phone
( ) - -

Father's First Name	Father's Last Name

Father's Cell Phone
( ) - -

Contact Email
Email Policy

Confirm Contact Email

Contact Email Two
Email Policy

Confirm Contact Email Two

Please do not forward my email address to Soccer Rhode Island (SRI). I am not interested in receiving information about soccer-related events and activities from SRI.

*Parents of players in the U6 and U7 age groups only: You may list the names of up to two friends that your son/daughter would like to play with. BYSA may not be able to honor special requests due to the size of the organization and the fact that various special requests may conflict.

If more than one entered in the Playing Requests entry boxes, your application will not be accepted

Playing Requests #1:* (only one name permitted)

Playing Requests #2:* (only one name permitted)

Emergency Contact Information
(In case of an emergency provide the name and phone numbers
of an individual who we can contact if a parent cannot be reached.)

Contact Name

Relationship to Player

Home Phone
( ) - -

Cell Phone
( ) - -

Medical Information

List any known medical problems such as asthma, allergies, medication allergies, diabetes, etc. If none apply, please indicate NONE:

Physician's Name

Physician's Phone
( ) - -

General Release of Liability, Indemnification

I, as parent or legal guardian, do hereby give my consent for my child to participate as a player in the Barrington Youth Soccer Association (BYSA). I understand and acknowledge that there is a risk of personal injury in soccer competition and, in recognition of these risks, do hereby release, hold harmless, and indemnify the Barrington Soccer Association, Soccer Rhode Island, US Youth Soccer Association, and US Soccer Federation and their officers, directors, coaches and designated officials from all claims, causes of action, and any and all liability which may result, directly or indirectly, from my child's participation.

Consent for Emergency Medical Aid and Treatment

I, as parent or legal guardian, do hereby give my consent for my child to receive emergency medical treatment which may be deemed advisable in the event of an accident or illness. I understand that, if possible, I will be notified by telephone of any emergency treatment required. I agree to be responsible financially for the cost of any treatment or assistance.