Mississippi Brilla Juniors – Permission to Roster Form
(Please fill out form completely)
Your Child has been offered a place on the Mississippi Brilla Juniors U______Division I soccer team. Your completion of this form and your payment of the registration fee (checks made payable to Division I Soccer) in the amount of $135 indicates your acceptance of this invitation and your agreement to play for the team indicated for the 2015-2016 soccer season (Fall 2015 through Spring 2016). Further, your acceptance indicates your agreement to fulfill all financial obligations to the team and the club for the 2015-2016 seasons. You are now a member. All team fees are divided equally amongst all players for activities and you are responsible for your share whether you attend or not. In order to register, you must provide the following information. (Registration is not complete until all necessary forms are complete.)
MS Brilla Juniors: U______Boys or Girls (Circle One)
Team Coach:______
Date of Birth:______
Player Name:______
Street Address:______
City:______Zip:______
Parents Names: Mother______Father:______
Email:______
Home #:______Mother Cell:______Father Cell:______
Emergency Contact(Name and #):______
List any medical concerns or allergies:______
Agreement, Release, Consent For Medical Treatment
I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the US Club, USYSA, MSA, MS Brilla Juniors, Clinton Soccer Association, and their affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer programs and activities, I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and personnel, including the owner of the fields and facilities used for the programs, against any claim by or on behalf of the registrant as a result of the registrant's participation in the programs and/or being transported to or from the same, which transportation I hereby authorize. As the parent or legal guardian of the above named player, I hereby give 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 the life, limb, or well-being of my dependent.
Signature of Parent/Guardian:______Date:______
By signing this form I give MS Brilla Juniors , Central District Soccer, MSA, US Club, and the USYSA permission to register my son/daughter for the above team for the August 1 – June 30 seasonal year.