Complete Both Sides of the Form. Mail Form with Check Payment to Arlington Soccer Club

FALL 2012 REGISTRATION FORM

Complete both sides of the form. Mail form with check payment to Arlington Soccer Club,

350 Mass. Ave. PMB 212, Arlington MA 02474. Up to 3 players may be registered using this form.

(Note: Credit Card online registration is preferred:

SPRING PROGRAMS: (Fee includes MYSA fees, League fees, Town of Arlington fees and Uniforms)

ProgramGradeAge GroupRegistration FeePracticeGame Day

U6 ClinicKindergarten8/1/06 – 8/31/07$70/seasonNo PracticeSaturday

U7 Clinic18/1/05 – 7/31/06$70/seasonNo PracticeSunday

U828/1/04 – 7/31/05$75/season(1) 1 hour/weekSunday

U9 38/1/03 – 7/31/04$90/season(1) 1.5 hour/weekSaturday

U1048/1/02 - 7/31/03$90/season(1) 1.5 hour/weekSaturday

U11 58/1/01 – 7/31/02$100/season(2) 1.5 hour/weekSaturday

U1268/1/00 – 7/31/01$100/season(2) 1.5 hour/weekSaturday

U147 & 88/1/98 – 7/31/00$105/season(2) 1.5 hour/weekSaturday

9129 - 128/1/94 – 7/31/98$85/seasonInformation available late August

For more program information, please go to our website:

CONSENT FOR MEDICAL TREATMENT (You must consent to the statement below to play soccer.)

I, the parent/guardian of the registrant(s), a minor(s), agree that the registrant(s) and I will abide by the rules of the ASC, its affiliated organizations and sponsors (‘Club”). Recognizing the possibility of physical injury associated with soccer and inconsideration for the “Club” accepting the registrant(s) for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the “Club”, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on the behalf of the registrant(s) as a result of the registrant’s participation in the Program’s and/or being transported to or from the same, which transportation I hereby authorize.

As parent or legal guardian of the below named player(s), I hereby give my consent for emergency medical care prescribed by a duly 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. I understand that such treatment will be sought and provided only in an emergency and that reasonable efforts will be made to contact me before providing such treatment.

Parent/Guardian Printed Name:______

Parent/Guardian Signature:______Date:______

PARENT PARTICIPATION: We need the help of parents to keep the teams operational and fun. (All coaches and volunteers associated with the Arlington Soccer Club will be CORI checked that is mandated by the Massachusetts Youth Soccer Association.)

Please circle areas of interest: Coach Asst. Coach Team Mgr. Referee General Help

Volunteer Name:______Volunteer Date of Birth:______

FAMILY EMAIL ADDRESS:______

Player 1 InformationProgram:______Grade Fall ‘12:_____

Last Name: ______First Name:______School:______

Date of Birth: ______Sex:___ Home Phone:______

Street Address: ______City: ______Zip: ______

Parent/Guardian Name: ______Cell Phone:______

Emergency Contact: ______Phone:______

Physician’s Name:______Phone:______

Ins. Company: ______Ins. Policy #: ______

Medical Issues? ______Allergies? ______

Player 2 InformationProgram:______Grade Fall ‘12:_____

Last Name: ______First Name:______School:______

Date of Birth: ______Sex:___ Home Phone:______

Street Address: ______City: ______Zip: ______

Parent/Guardian Name: ______Cell Phone:______

Emergency Contact: ______Phone:______

Physician’s Name:______Phone:______

Ins. Company: ______Ins. Policy #: ______

Medical Issues? ______Allergies? ______

Player 3 InformationProgram:______Grade Fall ‘12:_____

Last Name: ______First Name:______School:______

Date of Birth: ______Sex:___ Home Phone:______

Street Address: ______City: ______Zip: ______

Parent/Guardian Name: ______Cell Phone:______

Emergency Contact: ______Phone:______

Physician’s Name:______Phone:______

Ins. Company: ______Ins. Policy #: ______

Medical Issues? ______Allergies? ______

PAYMENT Player 1:$______

Player 2:$______

Player 3:$______

Late Fee(s):$______($25/Per Player if not postmarked by 6/19/12)*

TOTAL:$______

*Players in U6/U7 clinics are not charged late fees. However, placement on a team is not guaranteed after 6/19/12.

Fee waivers/scholarships are available by contacting . Refund Policy: Withdraw prior to 6/19/12, full refund minus $10 processing charge. Withdraw after 6/19/12, 50% of program fee.