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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
*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
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