MYSA (Marshfield Youth Soccer Association)

www.marshfieldyouthsoccer.org

2012 OUTDOOR LEAGUE Registration

Player Information: Returning Player Yes / No If yes, 2011 Team ____________ Uniform # ______

Last Name: _______________________________ First Name ____________________________

Address: _____________________________________________________________________________________

City: ______________________ State/Zip _____________________ Phone: ______________________

Date of Birth _____/ _____ / _____ Gender: M / F

Parent Home E-mail: __________________________ 2^nd E-mail: _______________________________

PARENT/LEGAL GUARDIAN INFORMATION :

Father’s Name :___________________________

Address:_____________________________________

Mother’s Name :______________________________

Address:________________________________

Phone# (Home/Work/Cell) ___________________ Phone# (Home/Work/Cell)_____________________

MAILING ADDRESS:

MYSA (Marshfield Area Youth Soccer)

Registrar

P.O. Box 636

Marshfield, WI 54449

Please make registration check payable to Marshfield Youth Soccer Association or MYSA

Check # Enclosed: __________ Amount: $_________ Number of registrations paid with this check: __

Checklist: ____ Parent/Guardian Signature Liability and Medical consent

___ $70 registration U10 or $110 registration fee U11 and up.  ($50 late fee added after Feb. 15th if applicable)

____Headshot photo for player ID card (1.5" by 1.5")

____Copy of birth certificate, new registrations only