Upson Soccer Association

Registration Form

Player’s Name:		Birthdate:
Address:		Male ( ) Female ( )
City:	County:	Zip Code:	Home Phone: ( )
Parent’s Name: Mother: Father:		Cell Phone: ( ) ( )
Email Address:
Any medical conditions that would affect your child’s participation?
Insurance Information: Company Name: Policy Number:
Shirt Size: (Please circle one) YXS YS YM YL AS AM AL		Sock Size: (Please circle one) S M L
		Mike Salter Donation: $_______________
Payment: Check #______ Cash ________		Payment Amount: $________________

I hereby give approval for the participation of my child in any and all GSSA and affiliated associations or league activities and I assume all risk and hazards incident to such participation, including transportation to and from said activities, waive, release, absolve, indemnify and agree to hold harmless the GSSA, USA, Thomaston-Upson Recreation Department and affiliated association league , the organizers, supervisors, officers, directors, participants and persons or parents supervising or transporting participants to or from such activities from any claim, arising out of injury to my child – I understand that a player who registers with affiliated league is bound to that league for the entire seasonal year unless a transfer is required for extenuating circumstances.

The Thomaston-Upson Recreation Department would like to notify parents/guardians that photos of individual players or teams will be taken for our sponsors and promotional projects and may be placed on department website.

I/We, the parents of the above named child, hereby give my/our permission to the person in charge of the activity to take my/our child to the doctor or hospital in case of injury. I/We understand I/We will be responsible for any and all cost incurred by emergency transportation or medical treatment provided.

I understand and agree. (Required Parent Signature) __________________________ Date:___________

________ I choose not to participate in the Rec One Insurance.

Volunteers:

USA depends on your participation. 99% of USA consists solely of volunteers. Without these volunteers, children may be turned away, which could include your child. We are especially in need of coaches and/or assistant coaches in the younger age groups. With USA training, guidance, and support, coaching a USA team is not beyond your abilities. Remember, without you, our volunteer, there is no USA.

I would like to: COACH _________ ASST COACH __________ AGE GROUP: U6 U8 U10 U12

**** NO REFUNDS AFTER TEAMS ARE DRAFTED****