Individual Adult Member Payment Form

Please fill out the form below to register an adult (coach, administrator, volunteer) with Massachusetts Youth Soccer. Please complete this form ONLY if you need to register as an "individual," that is, if you are not affiliated with any club or town team in Massachusetts. This form is simply for registration with Massachusetts Youth Soccer. It does not affiliate you with any towns or leagues!

An example of who would complete this form is an adult who is registering for a coaching course, and needs to be a Mass Youth Soccer member.

If you want to register a youth player with Massachusetts Youth Soccer, please use the Youth Member Registration Form.

The following information refers to the REGISTRANT, that is, the person registering with Massachusetts Youth Soccer.

Are you registering as an adult
member or a youth member? *

Adult

Youth

If you are registering a youth member, please

use the Youth Member Registration Form

First Name *

Last Name *

Date of Birth (MM/DD/YYYY) *

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Organization Name

Registrant's Gender *

Registrant Type *

Coach

Administrator

Volunteer

Other

Registering for Season *

2016-2017 (current season)

Reason For Registering *

Sign Me Up For *

All Mailings (Commercial & Soccer)

Mass Youth Soccer Mailings Only

No Mailings At All

I, the selfsame as the registrant, agree that I will abide by the rules of Massachusetts Youth Soccer, and US Youth Soccer, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and it consideration for the Massachusetts Youth Soccer/US Youth Soccer accepting the registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the Massachusetts Youth Soccer/US Youth Soccer, its affiliated organizations and sponsors, their employees and associated personnel, including owners of fields and facilities utilized for the Programs, against any claim by or on the 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. *

I WILL ABIDE BY THE ABOVE RULES AND RELEASE

As Parent/Legal Guardian of (or selfsame as) the above named registrant, 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 (me or) my dependent. *

I GIVE CONSENT FOR MEDICAL TREATMENT

I agree to pay $16.00 in order to register as an individual with Massachusetts Youth Soccer. I understand that if payment is not made, I will not be registered. *

A AGREE TO PAY THE $16 INDIVIDUAL REGISTRATION FEE