2017 Youth Soccer Registration Form
Player’s Name __________________________________ Gender _____
Age _____
DOB _____/______/______
Address ______________________________________ City _________________ St _______ ZIP ____________
Which division will the player be playing in?
3-5 year olds
6-7 year olds
8-9 year olds
10-12 year olds
ThedivisionisdeterminedbytheageyourchildwasonJanuary1st2017
Did the player participate last year? ______ If so, who was the coach?__________________________
Emergency Contact Information:
Name: ___________________________________ Phone: __________________________
Father’s Name ____________________________________ Father’s Work/Cell Phone ________________________
Father’s Email ____________________________________ Father’s Alternate Phone _________________________
Mother’s Name ___________________________________ Mother’s Work/Cell Phone ________________________
Mother’s Email ____________________________________ Mother’s Alternate Phone ________________________
Alternate Contact Name _____________________________ Alternate Contact Phone _________________________
Would either parent be willing to volunteer as a coach?
Yes
If so, Volunteer’s Name ______________________________
No
Preferred Position
Head Coach
Assistant
I acknowledge that I have read and I understand the “Waiver and Release” as printed on the back of this form.
Signature of Parent or Guardian____________________________________________ Date: ____________________
A Copy of the player’s Birth Certificate must accompany this form.
This only applies to 3 year olds.
To be filled out by Official Staff:
Resident $25.00
(Inside City Limits)
Early Registration Discount
Multi-Child Discount
Non-Resident $50.00
Late Fee $5.00
(Outside City Limits)
Receipt # _______________ TOTAL AMOUNT DUE: $_____________
ALLFORMSMUSTBERETURNEDTOTOWNHALLBYJULY15TH
MAIDENTOWNHALLISTHEONLYLOCATIONTHATFORMSANDPAYMENTS
AREACCEPTED;WITHTHEEXPECTIONOFEARLYREGISTRATIONDAY.
ShirtSize
_____Youthextrasmall(2-4)_____AdultSmall(34–36)
YouthSmall(6–8)
YouthMedium(10–12) AdultLarge(42–44)
YouthLarge(14–16)
AdultXLarge(46–48)
YouthXLarge(18–20) _____AdultXXLarger(50–52)
AdultMedium(38–40)
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Maiden Parks & Recreation
Waiver & Release of All Claims and Assumption of Risk
Please read this carefully and be aware that in signing up and participation in this program/activity, you will be
expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages, or loss
which you or your minor child/ward might sustain as a result of participating in any and all activities connected with
and associated with this program (including transportation services/vehicle operation, when provided).
I recognize and acknowledge that there are certain risks of physical injury to participants in the program/activity,
and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my
minor child/ward or I may sustain as a result of said participation. I further agree to waive and relinquish all claims I
or my minor child/ward my have (or accrue to me or my child/ward_as a result of participating in this
program/activity against Maiden Parks & Recreation, including its officials, agents, volunteers, and employees
(hereinafter collectively referred to as Maiden Parks & Recreation). (I do hereby fully release and forever discharge
Maiden Parks & Recreation from any and all claims for injuries, damages or loss that my minor child/ward or I may
have or which my accrue to me or my minor child/ward and arising out of, connected with, or in any way associated
with this program/activity.
Warning of Risk:
Recreational programs and activities are intended to challenge and engage the physical, mental, and emotional
resources of each participant. Despite careful and proper preparation, instruction, medical advice, conditioning, and
equipment, there is still a risk of serious injury when participating in any recreational program. Understandably, not
all hazards and dangers can be foreseen. Depending on the due to inclement weather, slipping, falling, poor skill level
or conditioning, carelessness, horseplay, unsportsmanlike conduct, premises defect, inadequate or defective
equipment, inadequate supervision, instruction or officiating, and all other circumstances inherent to indoor, outdoor,
and water related recreational programs exist. In this regard, it must be recognized that it is impossible for Maiden
Parks & Recreation to guarantee absolute safety.
Photo/Video Authorization:
I hereby give my consent for Maiden Parks & Recreation to use photos/ Video coverage of myself and/or minor
child/ward in future Maiden Parks & Recreation program guides, flyers, videos, websites, etc. I understand that
Maiden Parks & Recreation staff may take photos/video coverage of its programs and events, and their participants
from time to time and that these photos/video coverage remain the property of Maiden Parks & Recreation. Following
local distribution of these materials, requests for copies of photos/videos will be honored, when possible, but at my
expense.