Jacksonville Area Soccer Association Registration F o r m Fall 2017
Jacksonville A r e a Soccer Association Registration Form Fall 2017
L a s t Name:
F i r s t Name
Middle
Street
Initial St
City
Zio
Teleohone:
(
)
Did he/she play Spring 2017 ?: Yes B i r t h C e r t i f i c a t e copy r e c e i v e d ? : C e l l Phone #: (
B i r t h Date: No
/
/
Male
Female
Another Club Email:
)
D i v i s i o n : U-
#:
Team:
F a t h e r ^ s Name:
Occupation:
Business Phone :
Mother^s Name:
Occupation:
Business Phone :
( ) ( -)
V O L U N T E E R S N E E D E D (Please C i r c l e )
AUTHORIZATION TO PLAY
Coach
I a u t h o i i z e m y c h i l d t o play y o u t h soccei- w i t h the J a c k s o n v i l l e A r e a Soccer A s s o c i a t i o n ( J A S A ) . I , one o f tlie paients o r guardians o f t h e above n a m e d candidate, do hereby g i v e m y a p p r o v a l f o r m y c h i l d ' s p a r t i c i p a t i o n i n any and a l l soccer activities. I do release, absolve, a n d h o l d harmless the J a c k s o n v i l l e A r e a Soccei' A s s o c i a t i o n , and a l l others hsted hereafter; organizers, employees, officers, b o a r d m e m b e r s , coaches, refei ees, SJ>OBSOI&, supervisttta, a n d l a n d o w w a s ( p e n m i t t i n g t h e vise ot t h e i r l a n d f o r soccer a c t i \ ' i t k s ) , aB>- a n d a l l o t t h e m , I further agiee t o abide b y the rules, regulations and decisions rfJASA, the J A S A E x e c u t i v e B o a r d , officcars o r referees. I n case o f i n j u r y t o B K rf«ld I w a i v e a l l c l a i m s against organizers, sponsors or a n y supervisors appointed fliem
Asst. Coach
F i e l d Preparation
Team Manager
Concession Stand W o r k e r
J A S A is a n a l l - v o l u n t e e r o r g a r u z a t i o n dedicated t o p r o v i d i n g a n enjoyable and r e w a i ' d i n g soccer experience t o c h i l d r e n a n d theii" f a m i l i e s . J A S A receives n o d i i e c t p u b l i c f u n d i n g and the success o f our p r o g r a m i s directly due t o the h a r d w o r k o f v o l u n t e e r s . T h e parent/guardian o f each J A S A p l a y e r is expected t o v o l u n t e e r o n e h o u r per c h i l d , per season. Y o u r coach o r t e a m manager w i l l b e c a l l i n g u p o n y o u t o d o y o u r " d u t y . " P a r t i c i p a t i m o f J A S A parents keeps o u r operational costs d o w n , r e g i s t r a t i o n fees l o w , and is a b e n e f i t t o a l l .
Parent/Guardian" s I understand that I w i l l be called u p o n t o assist w i t h m y c h i l d ' s soccer p r o g r a m
P a r e n t / G u a r d i i m " s Signature
Date
FOR OFFICIAL USE ONLY PlaverFee:$ Date:
Signature
Fees (Please Circle):
Rec'dBv:
$50.00
Resistration Number:
S p a r k (U4-U6)
$60.00 U7-U8
A e e Division:
$70.00 R e c r e a t i o n (U9-U18)
Assigned Team:
Total A t n o u n t Enclosed: $ ( M a k e all checks payable to J A S A )
Emergency Information
Page
1 cf2
Fall 2015
Person t o n o t i f y i n an emergency:
Contact Address:
Conect Phone Number:
Doctor to n o t i f y i n an emergency:
Doctor-'s phone number:
Insurance Company:
Insurance ID Number:
Name of Primary Insured Pa r t y : Date of l a s t Tetanus (mm/yyyy):
Medications now being taken:
Player i s a l l e r g i c t o these medications and substances:
L i s t any unusual health information:
Page
2
L a s t Name:
F i r s t Name
Middle
Street
Initial St
City
Zio
Teleohone:
(
)
Did he/she play Spring 2017 ?: Yes B i r t h C e r t i f i c a t e copy r e c e i v e d ? : C e l l Phone #: (
B i r t h Date: No
/
/
Male
Female
Another Club Email:
)
D i v i s i o n : U-
#:
Team:
F a t h e r ^ s Name:
Occupation:
Business Phone :
Mother^s Name:
Occupation:
Business Phone :
( ) ( -)
V O L U N T E E R S N E E D E D (Please C i r c l e )
AUTHORIZATION TO PLAY
Coach
I a u t h o i i z e m y c h i l d t o play y o u t h soccei- w i t h the J a c k s o n v i l l e A r e a Soccer A s s o c i a t i o n ( J A S A ) . I , one o f tlie paients o r guardians o f t h e above n a m e d candidate, do hereby g i v e m y a p p r o v a l f o r m y c h i l d ' s p a r t i c i p a t i o n i n any and a l l soccer activities. I do release, absolve, a n d h o l d harmless the J a c k s o n v i l l e A r e a Soccei' A s s o c i a t i o n , and a l l others hsted hereafter; organizers, employees, officers, b o a r d m e m b e r s , coaches, refei ees, SJ>OBSOI&, supervisttta, a n d l a n d o w w a s ( p e n m i t t i n g t h e vise ot t h e i r l a n d f o r soccer a c t i \ ' i t k s ) , aB>- a n d a l l o t t h e m , I further agiee t o abide b y the rules, regulations and decisions rfJASA, the J A S A E x e c u t i v e B o a r d , officcars o r referees. I n case o f i n j u r y t o B K rf«ld I w a i v e a l l c l a i m s against organizers, sponsors or a n y supervisors appointed fliem
Asst. Coach
F i e l d Preparation
Team Manager
Concession Stand W o r k e r
J A S A is a n a l l - v o l u n t e e r o r g a r u z a t i o n dedicated t o p r o v i d i n g a n enjoyable and r e w a i ' d i n g soccer experience t o c h i l d r e n a n d theii" f a m i l i e s . J A S A receives n o d i i e c t p u b l i c f u n d i n g and the success o f our p r o g r a m i s directly due t o the h a r d w o r k o f v o l u n t e e r s . T h e parent/guardian o f each J A S A p l a y e r is expected t o v o l u n t e e r o n e h o u r per c h i l d , per season. Y o u r coach o r t e a m manager w i l l b e c a l l i n g u p o n y o u t o d o y o u r " d u t y . " P a r t i c i p a t i m o f J A S A parents keeps o u r operational costs d o w n , r e g i s t r a t i o n fees l o w , and is a b e n e f i t t o a l l .
Parent/Guardian" s I understand that I w i l l be called u p o n t o assist w i t h m y c h i l d ' s soccer p r o g r a m
P a r e n t / G u a r d i i m " s Signature
Date
FOR OFFICIAL USE ONLY PlaverFee:$ Date:
Signature
Fees (Please Circle):
Rec'dBv:
$50.00
Resistration Number:
S p a r k (U4-U6)
$60.00 U7-U8
A e e Division:
$70.00 R e c r e a t i o n (U9-U18)
Assigned Team:
Total A t n o u n t Enclosed: $ ( M a k e all checks payable to J A S A )
Emergency Information
Page
1 cf2
Fall 2015
Person t o n o t i f y i n an emergency:
Contact Address:
Conect Phone Number:
Doctor to n o t i f y i n an emergency:
Doctor-'s phone number:
Insurance Company:
Insurance ID Number:
Name of Primary Insured Pa r t y : Date of l a s t Tetanus (mm/yyyy):
Medications now being taken:
Player i s a l l e r g i c t o these medications and substances:
L i s t any unusual health information:
Page
2
