We understand that the League carries only minimal health insurance on each child.  We agree to use our private health insurance as the primary source of payment for medical care.

We the parents of ____________________________________________________________ give permission for emergency medical treatment of our child for illness or accident if we can’t be first contacted.

1st  Person to notify other than Parent/Guardian: _________________ _____________ Tel: _______________________

2nd Person to notify other than Parent/Guardian: ______________________________ Tel: ________________________

Does your child have any allergies or any special medical conditions that the coach needs to be aware of:    No     Yes

Explain: __________________________________________________________________________________________

In order for your child to participate, a signed registration form and fee  must be received by June 15th .  Player registration fee will be $50 if no uniform is required.  All subsequent children in the same family will pay $30 each for registration.  Uniform fee is $20 (Shirt, shorts, and socks).  New shirts($10 yellow or reversibile, $15 blue), shorts($10) or socks($5) may be purchased separately for returning players.  Please fill out a registration form for each participating child.  An application and all financial obligations to the league must be satisfied before your child may participate in practice sessions or play in a game.

Help the league by volunteering as a:

We hereby agree that Valley Youth United Youth Soccer Inc., its members, coaches and officers shall not be liable for injury of loss, which my child may sustain while participating in any Valley Youth United Youth Soccer activity. 

Parent / Guardian’s Signature: _________________________________________ Date: _____________________

Please mail this form, along with a check for all participating players registration and uniform fees, payable toValley Youth Soccer  by June 15, 2012. 

Send payment to:

Valley Youth Soccer Registration

7 Blythe Drive

Peckville, PA 18452

.................................................................................. Do not write below - Soccer league use only..  .................................................................................

 On database______    Received by Treasurer______   Copy for coach_____  Ok’d______ #_______