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Page 1: YEAR: WASA PLAYER REGISTRATION

WASA PLAYER REGISTRATION www.wadsworthsoccer.info

PO Box 504 Wadsworth, OH 44282 WASA DIVISION (INTERNAL USE ONLY)

Spring

Fall

SEASON: YEAR:

US Youth Soccer Player Membership FormOHIO YOUTH SOCCER ASSOCI ATION NORTH

(INTERNAL USE ONLY)PLAYER FEE $

PICTURE REC’D YES NO (Circle One)UNIFORM FEE $ BIRTH CERTIFICATE YES NO (Circle One)

DISCOUNT APPLIED $ TOTAL PAID $

LATE FEE $ CHECK NUMBER or CASH MAKE CHECKS PAYABLE TO WASA

TOTAL DUE $ RECEIVED BY DATE

Liability Waiver Form / Consent For Medical Treatment (MINOR) / GAASA Player Release & Code of Conduct

xPARENT GUARDIAN SIGNATURE PARENT GUARDIAN NAME (PLEASE PRINT) DATE

PARENT/GUARDIAN INFORMATION (WILL BE USED FOR COACHES AND WASA COMMUNICATION)

WE NEED YOUR SUPPOR T! PLEASE CHECK AREAS YOU WOULD BE WILLING TO HELP.

FATHER’S NAME EMAIL HOME PHONE CELL PHONE

MOTHER’S NAME EMAIL HOME PHONE CELL PHONE

EMERGENCY CONTACT’S NAME RELATIONSHIP PHONE

PLAYER INFORMATION

LAST NAME FIRST NAME MALE/FEMALE BIRTH DATE (MMDDYYYY)

ADDRESS

OHCITY STATE ZIP

KNOWN ALLERGIES/ MEDICAL CONDITIONS LAST TEAM PLAYED ON

IF YOU DO NOT HAVE A UNIFORM, PLEASE SELECT THE CORRECT SIZE BELOW.-Rec League (U8 & under) Jersey - ($16) Size => (Jerseys may be reused for all levels of Rec League)

Travel League (U9 & up) Jersey - ($30) Current Jersey #:* New Jersey are REQUIRED for New Players and and Players that did not purchase them in the Fall of 2011 or After (Includes Red & White Jersey)

NEW PLAYER:

If Returning Player:

FM

YS YM YL AS AM

YS YM YL AS AM

I, the parent/guardian for the above child, release, discharge, and/or otherwise indemnify the organization/league/club for which I am registering the child to play, Ohio Youth Soccer Association North, it’s affiliated sponsors, employees and associated personnel, including the owners of fields and facilities utilized against any claim by or on behalf of the registrant as a result of his or her participation. Furthermore, I hereby give my consent to have a coach, athletic trainer; emergency personnel and/or doctor of medicine or dentistry provide my son/daughter with medical assistance and/or treatment and agree to be responsible financially for the reasonable cost of such assistance and/or treatment. Travel players only: I have read and agree to the terms of the GAASA Player Release Waiver and Code of Conduct which can be found at: http://www.gaasa.org/. By signing below and submitting this Registration form, I acknowledge that: I am the parent/guardian authorized to consent on the player’s behalf; I have reviewed this form and the information it contains and represent that it is accurate; and I agree to submit this form with the intent to be bound by its terms and conditions.

AL AXL

YS YM YL AS AM AL AXL

S M L

Travel League (U9 & up) WASA RED Shorts - If Needed ($15):

Travel League (U9 & up) WASA RED Socks - If Needed ($9):

Size =>

Size =>

Size =>

Head Coach Assistant Coach

SPECIAL REQUESTS/COMMENTS

LAST SEASON PLAYED

MOTHER'S BIRTHDAY (MMDD):

*** ALL Jersey, Shorts, and/or Socks ordered will be paid for at time of pick-up. You will be notified by email of pick-up times and location. ***

Fundraising / Sponsor Coordinator/Administrator

Cost to Play: U4-U6: $60 U7/U8: $70 U9-U14: $95 (Full Payment due with Registration - Make Checks Payable to WASA)

PLAYER ADDED TO WEB