Havre Youth Soccer Association Fee pd ______________

Havre
Mail to: Youth Soccer
PO Box 2118 Havre,Association
MT 59501
NEW EARLY DEADLINE!
Date Rcd____________
or deliver
Mail to: POto Grams or Gary and Leo's IGA
Box 211 JUNE 15TH, 2017 Check No. ____________
Season will run August 14, 2017 to October 6, 2017 Other________________
NEW PLAYERS MUST INCLUDE A COPY OF A CERTIFICATE OF LIVE BIRTH WITH REGISTRATION
PLAYER REGISTRATION (1 form per player)
Last Name _______________________________ First Name ___________________________ MI _____
Address ______________________________________________________________________________
City ________________________________________ State _____________ Zip Code _______________
Email ______________________________________________ Phone ____________________________
Birthday ______________ Age __________ Grade in Fall 2017 ______________ Circle One M F
Last season Played __________________________
Mother / Guardian _________________________________________ Phone ______________________
Father/ Guardian ___________________________________________ Phone ______________________
Emergency Contact Besides Parent/Guardian _________________________________________________
Phone _______________________ Relation to Player __________________________________________
Doctor _________________________ Clinic ______________________ Phone ______________________
PARENTAL SUPPORT: We need participation from parents in our program. Circle the areas in which you are willing to help. Indicate the
best way to get ahold of you, phone or email and size shirt if coaching. If we do not have enough coaches, your child may not play.
__________________________________________________________________________________________________
COACH ASSIST. COACH EQUIPMENT MANAGER FIELD PREPARATION FIELD MARSHALL
AGE SUPERVISOR SPONSOR CONCESSIONS BOARD REFEREE
UNIFORMS I, the parent/guardian of the registrant, a minor, agree that I and the player will abide by the rules
and regulations of Havre Youth soccer, it's affiliated organizations, and its sponsors (Havre Youth
Youth Adult
Soccer "Parties"). In consideration of the player's participation in the soccer programs and activities
CHILD JERSEY M L S M L XL 2XL 3XL of Havre Youth Soccer Parties (the Programs), I , for myself, the player, and our respective heirs,
COACH/ASSIST S M L XL 2XL 3XL administrators, and successors, intending to be legally bound, herby release and indemnify Havre
SOCKS M L Youth Soccer Parties, the owners and operators of the facilities used for the programs, and their
respective officers, directors, employees, agents, and representatives from and against all claims,
liabilities, damages, or causes of action arising out of or in connections with the players
OTHER CHILDREN IN FAMILY PLAYING & GRADE
participation in the Programs including, without limitation, players transportation to/from any
_________________________________________ Program which transportation is hereby authorized. I further grant Havre Youth Soccer Parties the
_________________________________________ right to use the players name, picture and/or likeness in printed, broadcast, and other material
_________________________________________ concerning the Programs provided such use is related to the player's status as a participant in the
Programs.
REGISTRATION FEES ARE AS FOLLOWS:
______________________________________________________
Child must be 4 by 9/10/2017
May 1 to June 15 $35 for first child, $30 Signature of Player Date
each additional child
______________________________________________________
June 16 to July 10 $45 for first child, $40 Signature of Parent Date
each additional child
CONSENT FOR MEDICAL TREATMENT (MINOR)
After July 10th will be per availability only As the parent or legal guardian of the above-named player, I hereby give consent for emergency
medical care prescribed by a licensed Doctor of Medicine or Doctor of Dentistry. This care may be
and placement is not guaranteed. given under whenever conditions are necessary to preserve the life, limb, or well-being of my
Registration fees help keep the organization going by dependent.
paying field preparation, referee, insurance and ______________________________________________________
uniforms. Of the registration fee, all is refundable up Insurance Company Name of Insured Policy Number
until the first day of games except $10 for proc. fee.
Please make checks to HYSA. ______________________________________________________
NOTE : FEES MUST ACCOMPANY THE REGISTRATION Signature of Parent/Guardian Date
FORM; PLAYER WILL NOT BE ROSTERED UNTIL ALL
FEES ARE COLLECTED. Some Scholarships may be
available, contact us for info.