2012 Anna Recreational Fall Soccer Registration U6 & U8 Ages 4 – 7 (on July 31, 2012) Sponsored by the Anna Rocket Athletic Boosters Office Use Only Please complete the form below and return it with your payment to the Elementary or Middle school office, open registration or mail to: Anna Youth Soccer Anna Elementary School P.O. Box 169 Anna, Oh A form must be completed for each child and both sides completed. The forms and payment need to be turned in by May 11, Website: Contact Information: Director: Lisa McEldowney Nicole Gannon Coaches will contact team members at the end of July Shirt Size (Circle One) Youth YS YM YL Adult AS AM AL AXL Wants to be on the same team as brother / sister / carpool (Not Guaranteed) Name: __________________________ Played at least 1 yr Player Name : Birthday Age on July 31 st Must be 4, 5, 6, or 7 yrs old Grade Fall 2012 Parents address Experience Level New Player __/__/__ Mo Day Year Gender The Fees for all soccer teams and age groups are: Booster Member Non Member First Child $35.00 $45.00 Each addt’l child $30.00 $40.00 Make checks payable to: Rocket Athletic Boosters If you would like to join or renew your Rocket Athletic Boosters Membership and take full advantage of the Booster member discount, please add your $25.00 membership dues below. You may write one check for sign-ups and membership fees. Booster MemberNon MemberExample First Child 2 nd Child 3rd Child TOTAL Booster Membership Office Use Only $35.00 $30.00 $25.00 $90.00 Amount Enclosed $ _________________ Cash Check #________ Volunteers Needed This soccer program is 100% dependent on volunteers! If you are able to get more involved please indicate below. ***There is no experience necessary to coach. We offer training courses and resources. Please circle preference: I would like to Coach Asst. Coach Referee Fields Pictures Name:_________________________ Contact Info:____________________________________ T-shirt Size if coaching: S M L XL XXL XXXL (Circle One) Open Registration Anna Elementary School May 8, :30 – 6:00 I would like my child to play in the Anna Youth Soccer program in the Fall of I will not hold the Anna Local Schools, Rocket Athletic Boosters, coaches or any assistant coach responsible for any accidents or injuries that occur while participating in this program PARENT SIGNATURE___________________________________________________ DATE _______________

EMERGENCY MEDICAL AUTHORIZATION FORM Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children who become ill or injured while participating in the Rocket Athletic Booster Fall Soccer Program. Player Information Last Name: First Name: Street Address: City: State: Zip Code: We will be using One Call Now again this year to relay valuable information. Please designate up to two phone numbers below that you would like to have called. Mother / Guardian Name: Home phone #: Cell Phone #: Work Phone #: PART 1 OR PART 2 MUST BE COMPLETED Emergency Contact Name: Home phone #: Cell Phone #: May child be given Tylenol or Advil (check one): Yes No Part 1 I HEREBY CONSENT FOR THE FOLLOWING MEDICAL CARE PROVIDERS AND LOCAL HOSPITAL TO BE CALLED: Allergies Physician: Phone: Dentist: Phone: Hospital: Phone: Medications being taken: In the event reasonable attempts to contact me have been unsuccessful, I hereby give consent for: 1) the administration of any treatment deemed necessary by above-named doctors, or in the event the designated practitioner is not available, by another licensed physician or dentist: and 2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the medical opinions of two other licensed physicians or dentist concurring in the necessity for such surgery are obtained prior to the performance of such surgery: Facts concerning the child’s medical history, including allergies, medications being taken, and impairments to which a physician should be alerted are noted above. SIGNATURE OF PARENT/GUARDIAN:____________________________________________DATE:______________________ PART 2 REFUSAL TO CONSENT: I do not give consent for emergency medical treatment of my child. In the event of illness or injury requiring emergency treatment, I with the proper authorities to take the following action____________________________________ SIGNATURE OF PARENT/GUARDIAN:________________________________________________________DATE_____/_____/_____ Father / Guardian Name: Home phone #: Cell Phone #: Work Phone #: