First Name:
Last Name:
Date of Birth:
Gender: --- Male Female
Phone:
Address:
City:
State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming
Zip Code:
Name:
Email:
Conditions:
Physician:
Physician Phone:
Emergency Contact:
Emergency Contact Phone:
Jersey: --- Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large
Shorts: --- Youth Small Youth Medium Youth Large Adult Small Adult Medium Adult Large Adult X-Large
Socks: --- Youth Adult
Please select 'Yes' if you are new to the Fall program: --- Yes No
Please select 'Yes' if you allow us to potentially use your child's picture on the league's social media webpages: --- Yes No
Recognizing the possibility of physical injury associated with soccer in consideration for Mass Youth Soccer accepting my child to the Acushnet Youth Soccer, I hereby release, discharge and/or otherwise indemnify Mass Youth Soccer, its affiliated organizations, including, but not by way of limitation, the fields and facilities used for Acushnet Youth Soccer, against any claim by me or on my behalf of my child as a result of my child's participation at Acushnet Youth Soccer and or being transported to or from any practice or competition associated with the Acushnet Youth Soccer which transportation I hereby authorize. My child has received a physical examination by a physician and has been found physically capable of participating in soccer. I hereby give my consent to have an athletic trainer, emergency medical technician and/or Doctor of Medicine or dentistry provide my child with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of such assistance and/or treatment.
Name of Parent/Guardian:
Today's Date:
If possible, please upload a picture of the player's birth certificate for age group verification.
Proceed to Payment
