1. Include this form with check or money order made payable to HYSA ALL registrations need to include a copy of their birth certificate. MAIL TO: HYSA, P.O. BOX 992, BUDA, TX 78610 OR Register online at www.haysyouthsoccer.orgwww.haysyouthsoccer.org PLEASE PRINT PLAYER INFORMATION Last Name FirstMiddle AddressCity Zip Home Phone Player date of birth Gender M F Player’s Age Group – Circle Bracket Division 4 U5 Coed(8/1/09 to 7/31/10) Fee $80 U6 Coed(8/1/08 to 7/31/09) Fee $95 U8 Boys/U8 Girls(8/1/06 to 7/31/08) Fee $110 U10 Coed(8/1/04 to 7/31/06) Fee $115 Player’s Age Group – Circle Bracket Division 3 U12 Boys/U12 Girls (8/1/02 to 7/31/04)Fee $130 U14 Boys/U14 Girls (8/1/00 to 7/31/02)Fee $130 U15 Boys/U15 Girls (8/1/99 to 7/31/00)Fee $130 U16 Boys/U16 Girls (8/1/98 to 7/31/99) Fee $130 U18 Boys/U18 Girls (8/1/96 to 7/31/97) Fee $130 Mother’s NameCell # * Email Father’s Name Cell # * Email * Email is a required field. As the parent or legal guardian of the above named player, (1) I hereby give consent to emergency medical care prescribed by a duly licensed doctor of medicine or doctor of dentistry. This care may be given under any condition necessary to preserve life, limb or well-being of any dependent. (2) I agree that the registrant and I will abide by the rules of United States Youth Soccer (USYS) and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for USYS accepting the registrant for its soccer programs and activities (hereafter called the Program), I hereby release, discharge and/or otherwise indemnify the USYS, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Program, against any claims by/on behalf of the registrant as a result of the registrant’s participation in the Program, and/or being transported to or from the same, which transportation I hereby authorize. AND (3) I acknowledge that HYSA has a ZERO TOLERANCE Policy as stated in HYSA Section 3 rules. Comments and/or actions being perceived as negative or confrontational toward any player, coach, referee, parent, or spectator WILL NOT BE TOLERATED. HYSA COMPLEX is PRIVATE PROPERTY, and therefore HYSA reserves the right to ban any individual from the complex. SIGNATURE of PARENT or LEGAL GUARDIAN:DATE: LIST ANY SPECIAL REQUEST, PLAYER MEDICAL PROHIBITIONS/LIMITATIONS BELOW: Examples: Request to play in older age bracket; placement w/particular team/coach; asthma; etc. Parent/Legal Guardian signature REQUIRED to complete registration. PARENTAL SUPPORT – For HYSA to work, we need active participation from ALL families in the Program. Each family is required to commit to 4 hrs (2 hrs - Facilities & 2 hrs – Concession) of volunteer work and a mandatory fundraiser per season or choose to opt out and pay the opt out fee(s), due at time of registration. Please note, only one opt out fee is required per family (not per child). **CIRCLE OPTION** Facility Volunteer OR Opt Out $25 Concession Volunteer/Donate OR Opt Out $25 Fundraising OR Opt Out $25 TEAM SUPPORT – Please circle any areas which you would be interested in assisting: REFEREE *HEAD COACH *ASSISTANT COACH BOARD MEMBER *counts towards volunteer hours ALL COACHES MUST BE REGISTERED WITH KidSafe AND HAVE THEIR COACH LICENSE(S) ON FILE **Registrations postmarked after deadline will be assessed a $15 Late Fee and subject to team availability on a first come, first serve basis ** OFFICIAL HYSA USE ONLY Registration Received Date Volunteer Opt Out Total Due Fee Due Late Fees Payment Received SPRING 2015