Dorchester County Family YMCA

2007 Youth Soccer

Registration Form

If  Paying by MasterCard/Visa you may register by fax

YMCA Fax # 410-221-0514

Child’s Name___________________________________________________________________________________

Date of Birth____________________________________________________________________________________

Address________________________________________________________________________________________

City____________________________________________________________________________________________

Child’s primary Home phone #_____________________________________________________________________

Second home phone #_____________________________________________________________________

School as of 9/1/07_______________________________________________________________________________

Mother/ Guardian’s name__________________________________________________________________________

Work Place_____________________________________________________________________________________

Work phone________________________________ Cell phone__________________________________________

Father/ Guardian’s name__________________________________________________________________________

Work Place____________________________________________________________________________________

Work phone________________________________ Cell phone__________________________________________

# Of seasons your child has played YMCA soccer       _______                Dorchester Y member?_____  Yes   ______   No

Shirt size: _______              youth small 6-8 _______ youth medium 10-12               ________ youth large 14-16

________ Adult medium   ________Adult large

Please order next larger size if you have any doubts.

Reorders are at the expense of the parents, $8 youth size, $10 adult size

Please contact me about coaching____________________ initial, please

Please contact me about sponsoring a team_____________initial, please

I would like to volunteer as a team mom or dad (circle one please)

I would like to assist as a referee (initial please) ____________               

FOR FAXED CREDIT CARD USE ONLY MASTERCARD/VISA #  ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ ____ EXP DATE   ________/______                                                 V-Code (validation code) ____________ Signature __________________________________________ Date __________________________

                Waiver & Release

Parent/ Guardian Authorization: I give my child _______________________________________ permission to participate in Dorchester County Family YMCA activities. I understand that even when every reasonable precaution is taken, accidents can sometime still happen. Therefore, in exchange for the YMCA allowing my child to participate in YMCA activities, I understand and expressly acknowledge that I release the YMCA and its staff, members, volunteers, and sponsors from all liability for any injury loss or damage connected in any way whatsoever to participant in based on negligence, action, or inaction of the YMCA its, staff, directors, members and guest. I have read and am voluntarily signing this authorization and release. I understand that the YMCA does not carry accident insurance and I will be responsible for any medical claims that may arise from my child’s participation.

Parent/ Guardian signature __________________________________ Date __________________

Office use: ________ Registration Date _________ Receipt _________ Staff Initials__________