Webutuck Valley Youth Soccer League
2015 Registration Form
Player name:_______________________________________________________ Male________ Female________
Address:____________________________________________________________________________________________
Age (as of September 1, 2015) ________ Grade (as of September 2015) ________
Mother’s name____________________________________________ Mother’s cell #__________________________________
Father’s name_____________________________________________ Father’s cell #__________________________________
Home phone___________________________________ Email_______________________________________________________
Emergency contact_________________________________________ Emergency # __________________________________
Legal Guardian name________________________________________________ cell #__________________________________
Shirt size (please circle) YS(4/5) YM(6/7) YL(8/10) AS AM AL
Short size (please circle) YS YM YL AS AM AL
Player registration fees (must be received by August 7th)
$45.00 – Tiny Tots program ages 4-5 (Saturday mornings only)
$60.00 – individual player grades 1st -7th (Saturday games and 1 practice per week)
$10.00 – late registration fee (received after August 7th) uniforms will be ordered Aug 8th
Register by mail to: Allen Lazarus, 4531 Route 199, Millerton, N.Y. 12546
Please include check made out to: WVYSL
Please indicate how you would like to support the program
coach field preparation uniforms
I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the WVYSL code of conduct for players, parents and coaches. I know that by participating in soccer there may be injuries and protective equipment does not prevent all injuries to players, and do hereby waive, release, absolve, indemnify and agree to hold harmless the Webutuck Valley Youth Soccer, Inc., its coaches, agents, organizers, supervisors, participants and the Town of Amenia from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving said minor arising out of the minor’s attendance in the program.
Parent/Legal Guardian Signature:___________________________________________________________________________________
Parent/Legal Guardian Name (print):________________________________________________________________________________
Please indicate any physical limitations your child may have (allergies, sight, hearing, etc.)
___________________________________________________________________________________________________________________________
***Office use only***
Date received: _______________ Amount received _______________ Cash: __________ Check #: __________
