SSA - Springfield Soccer Association (Holland, OH)

Instructions:

Complete the following form.
When you are done you will be taken to a page that you should print.
You will have the option to pay ONLINE, MAIL-IN, or BRING-IN to our open enrollment day.

Note: You will need access to a printer to print your confirmation on the next page. Forms received without payment will not be registered to play.

* - Required Field
First Name	*
Last Name	*
Middle Initial
Male/Female	*
DOB (MM/DD/YYYY)	/ / *
Mother's Birth Month	*
Mother's Birth Day	*
Seasons of Recreational Experience	(0 if none) *
Seasons of Travel Experience	(0 if none) *
School	*
Grade	*

# Players Playing for SSA
Parent/Guardian Last Name	*
Parent/Guardian First Name	*
Home Telephone XXX-XXX-XXXX
Cell Telephone XXX-XXX-XXXX
Can we Text to this number?	*
Address	*
City	*
Postal Code	*
E-Mail Address	*

Emergency Contact Name (different than above)	*
Emergency Contact Telephone Number	*

Preferred Practice Night	*
Secondary Practice Night	*

If your player has any medical condition, please enter the information in this box.

SSA will form teams blindly based on the night players are available to practice. Whenever possible, players from the same household will be given the same practice night but this cannot be guaranteed. No other requests will be considered. Every effort will be made to keep teams together from Fall to Spring but this will not always be possible. Any request to transfer a player must be submitted in writing for consideration by the board (except to correct practice night/household requests).

By checking the box, I acknowledge that: I am the parent/guardian of the player authorized to consent on the player’s behalf.

By checking the box, I the parent/guardian for the above child release, discharge and/or otherwise indemnify the organization/league/club for which I am registering the child to play, Springfield Soccer Association, US Youth Soccer, the Ohio Youth Soccer Association North, its affiliated sponsors, employees and associated personnel, including the owners of fields and facilities utilized against any claim by or on behalf of the registrant as a result of his or her participation.

By checking the box, I acknowledge that: I am the parent/guardian of the player authorized to consent on the player’s behalf; I have reviewed this form and the information it contains and represent that it is accurate.

By checking the box, I give my consent to have an athletic trainer, coach, paramedic, and/or doctor of medicine or dentistry provide medical assistance and/or treatment. I agree to be financially responsible for the reasonable cost of such assistance and/or treatment. This consent does not apply to major surgery unless surgery must be performed to treat an emergency condition. Attempts will be made to contact parents of players participating in the program based on information provided on this form.

By checking the box, I acknowledge that: I am the parent/guardian of the player authorized to consent on the player’s behalf; I have reviewed this form and the information it contains and represent that it is accurate.

Fee will be determined by the player's age on July 31, 2011. U4, U5, U6 is $25.00 U7+ is $40.00
$15 Jersey Fee	(Note: A reversible Springfield Soccer Jersey is required for play. If you have one from last season and it is in good condition you do not need to purchase a new one. Black socks, black shorts, and shin guards are also required. Cleats are recommended but not required.
	If you require a jersey, please specify a size.

You are not done. Please click the submit button one time.