THE DISTRICT DOES NOT SPONSOR THIS EVENT AND THE DISTRICT ASSUMES NO RESPONSIBILITY FOR IT. IN CONSIDERATION
OF THE PRIVILEGE TO DISTRIBUTE MATERIALS, THE NORTH MASON SCHOOL DISTRICT SHALL BE HELD HARMLESS FROM ANY
CAUSE OF ACTION FILED IN ANY COURT OR ADMINISTRATIVE TRIBUNAL ARISING OUT OF THE DISTRIBUTION OF THESE
MATERIALS, INCLUDING COSTS, ATTORNEY’S FEES AND JUDGMENTS OR AWARDS.
SOCCER 2015
NORTH MASON YOUTH SOCCER CLUB
REGISTRATION FORM
2015 Fall Registration April 1 – July 17, 2015
Late Registration July 18 – August 1, 2015
Late registrations may be wait-listed.
Register: - on line www.nmysc.org or by mail to: NMYSC P.O. Box 905 Belfair, WA 98528
Refer to Website for in-person dates.
Registration Fee (Before 7/17)
Late Registration Fee (After 7/18)
U5, U6, U7 . . . . . . . . . . . . . . . . $60
U5, U6, U7 . . . . . . . . . . . . . . . . $80
U8 and up . . . . . . . . . . . . . . . . . .$80
U8 and up . . . . . . . . . . . . . . . . . $100
($10 discount for additional players in same family. Max. $200 registration per family)
Uniform set $20, if player does not already have one. Includes jersey, shorts and socks.
***All first time NMYSC players must submit a copy of their birth certificate***
PLAYERS WILL BE WAITLISTED UNTIL PAYMENT IS RECEIVED OR PAYMENT
PLAN ARRANGED WITH TREASURER!
PLAYER'S LAST NAME_______________ MI:____ PLAYER'S FIRST NAME____________
PLAYER'S DATE OF BIRTH (mm/dd/yy)________________________________SEX: M
F
PLAYER'S AGE BEFORE AUG. 1_________________
PLAYER’S UNIFORM SIZE (circle one):
YXS YS YM YL
AS AM AL AXL
PLAYER'S MAILING ADDRESS _________________________________________________
CITY________________ ZIP CODE______________PHONE#__________________________
PARENT/GUARDIAN NAME______________________________ (relation) ______________
PARENT'S EMAIL ADDRESS____________________________________________________
MAILING ADDRESS (if different) ________________________________________________
CITY________________________ ZIP CODE______________ PHONE#_________________
IS PLAYER A RETURNING PLAYER FROM LAST SEASON? (circle one)
YES
NO
IF "YES" COACHES NAME______________________________________________________
Would you like to help? [ ] Coach
www.NMYSC.org
[ ] Assistant coach
360-277-4468
[ ] Fundraising
[ ] Sponsor
NMYSC P.O. Box 905 Belfair, WA 98528
Nonprofit UBI 602 695 579
MEDICAL RELEASE FORM
As the parent/legal guardian of
, I request that in my absence the
above-named player be admitted to any hospital or medical facility for diagnosis and treatment. I request and
authorize physicians, dentists, and staff duly licensed as Doctors of Medicine or Doctors of Dentistry or other
such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative
procedures and x-ray treatment of the above named minor. I have not been given a guarantee as to the results of
examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue taken
form the above-named player.
Date of Player's Birth (mm/dd/yy)
Date of last Tetanus Booster
Known allergies including any allergies to medicine of this player
Any medical problems that should be noted
Family Physician
Phone#
Name of Parent/guardian
Address
City/State/Zip
Cell#
Home#
Work#
Person responsible for charges if different from above)
Address
City/State/Zip
Cell#
Home#
Work#
Person to notify if parent/guardian is unavailable
Cell#
Home#
Work#
Insurance Provider
Policy #
Signature of Parent/Guardian-
www.NMYSC.org
360-277-4468
NMYSC P.O. Box 905 Belfair, WA 98528
Nonprofit UBI 602 695 579