|
WILMINGTON YOUTH SOCCER
INTOWN REFEREE REGISTRATION
Participants Name: __________________________________________
(Last) (First)
Date of Birth: ____________ Grade (Fall 2010):_________ □ Male □ Female
Address: _______________________________ Home Phone: ______________
E-mail address for game assignments and notifications (please print):
________________________________________________________________
Parent/Guardian name:
______________________________________________
Parent/Guardian e-mail Address (if different from above):
________________________________________________________________
Emergency Emergency
Contact Name: ____________________________Telephone: ______________________
Medical Conditions: ________________________________________________
WYSA Team: ____________________ Coach’s Name: _____________________
PARTICIPATION RELEASE AND CONSENT FOR EMERGENCY MEDICAL TREATMENT
My signature on this release allows my child to participate as a referee for Wilmington Youth Soccer Associations In-Town games.
I certify that my child is in excellent physical health, and may participate in strenuous and physical activities, including playing soccer, refereeing soccer matches and training for the purpose of refereeing soccer matches. Recognizing the possibility of physical injury associated with soccer, I hereby release, discharge, and indemnify Wilmington Youth Soccer Association and all its affiliated entities, including the owners of the fields and facilities utilized for the programs, from any and all Liability, claims, demands, and causes of action for personal injury, property damage and/or other loss suffered by my child in connection with his/her participation as a referee for WYSA.
Additionally, as the parent or guardian of the above named participant, I hereby give my consent for emergency medical care prescribed by a fully licensed doctor of medicine or doctor of dentistry. This care may be given under whatever conditions are necessary to preserve life, limb or well being of my dependent.
Parent / Legal Guardian Signature: ___________________________________ Date: ___________
P.O. Box 107, Wilmington, MA 01887
(978) 657-8889
|
