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Please print this form or Download This Form for Adobe Acrobat
and bring a copy of it to registration sign ups. Havelock Youth Soccer Association
P.O Box 671 Havelock, North Carolina 28532  CHECK AGE CHART HERE | Soccer Registration Form
Medical Consent
Waiver of Liability Release
| | Challenge ________ Div ______
Date ____________ Initial _____
Check # _____________ Cash _____ Official Use only | Please Print | | YXS YS YM YLG AS AM AL | | Last | First | Middle | | | PLAYER'S
NAME ___________________________________________________ PHONE __________
ADDRESS _______________________________________________ DOB____/____/____
CITY ______________________________ STATE __________ ZIP __________
SEX ______ PARENTS EMAIL ___________________________
FATHER'S NAME ______________________________ WORK PHONE ________________________
MOTHER'S NAME _____________________________ WORK PHONE ________________________
MEDICAL INSURANCE CARRIER ______________________________________________________
SPECIAL MEDICAL CONDITIONS _____________________________________________________
EMERGENCY CONTACT _____________________________________ PHONE ________________
If you want brother/sister on same team, enter siblings name ______________________________________
Siblings must be within the same age division.
PLAYERS ARE NOT ALLOWED TO PLAY OUT OF THEIR AGE GROUP. VOLUNTEERS | | FATHER | _________COACH | __________ASST.COACH | | MOTHER | _________COACH | __________ASST.COACH | | We the parent or guardian of the above named individual acknowledge that participation in athletic events necessarily involves risk of physicalinjury. We the undersigned do hereby assume responsibility for any injury incurred that may result from my child's participation in the Havelock YouthSoccer Association (HYSA) Program. I hereby remise, release, and forever discharge the HYSA and all others listed hereafter: organizers, sponsors,officers, board members, commissioners, coaches, and landowners permitting the use of their land for soccer activities, I agree to abide by the rules,regulations and decisions of the HYSA and the Eastern Carolina Soccer Association, and agree to disciplinary actions taken by the above namedassociations boards, officers and referees. | | In addition, we, the undersigned, do hereby authorize any team coach or designated adults of the team, if after a reasonable attempt has beenmade to reach the parent or guardian to obtain consent or if sound medical practice decrees there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care, to be rendered to the registrant under general or specialsupervision and the advice of any physician or surgeon duly licensed to practice. We do consent to any x-ray examination, anesthetic, dental or surgicaldiagnosis or treatment and hospital care to be rendered to the registrant by any dentist duly licensed to practice. | We __________________________________________ the parents or legal guardian of the registrant,
| | Parents/Legal Guardian Signature | _____________________________ a minor child, wishing to participate in the Havelock Youth Soccer program, have read and fully understand and agree to the Waiver of Liability.
Please print this form or Download This Form for Adobe Acrobat
and bring a copy of it to registration sign ups.
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