BILLERICA YOUTH SOCCER ASSOCIATION REG FORM
SPRING SOCCER SEASON - 2011 
http://www.BillericaSoccer.org
Parent Name:       _______________________________________________________
      Parent Address:  ______________________________________________________

# 	Last Name             First Name           Date of Birth       2010 Age        Medication  (Y/N)1    Fee (See Below)

1
2
3
4
5

(1)If your child has any medical condition/medication that BYSA should be aware of, please use the back of this form to describe 

BYSA season fees: $60.00 per Child, $1500 late fee for registrations received after July 31st
 
Address: 
Street: ____________________________ City: ______________ STATE: ___ ZIP: ________ 
Phone: Business: 
Home: Cell: 

Email: __________________________ Secondary Email: __________________________ 
Health Plan Name: ______________________________ Insurance ID#: ______________________________ 

I, the parent/guardian of the registrant, a minor, agree that the registrant and I will abide by the rules of the USYSA, its 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 (the "Programs"), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, 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 as a result of the registrants participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. Consent for Medical Treatment (Minor) As parent or legal guardian of the Minor player, 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. PLEASE NOTE OUR REFUND POLICY: : Any requests for refunds before the season starts will be subject to a $15.00 fee, which covers nonrefundable state and regional affiliation fees including insurance and registration processing charges. Refunds will not be granted once the season starts. REFUNDS ARE NOT DONE THROUGH YOUR CREDIT CARD OR BY CREDITING THE CREDIT CARD PAYMENT. BYSA WILL PROVIDE A CHECK IF A REFUND IS NECESSARY. 
Parent/Guardian: Print Name: ________________________ 

Signature: ________________________ (Spouse or second guardian name)
Date: ________________________ ________________________

If mailing this registration send to: Billerica Youth Soccer Association P.O. Box 223 Billerica, MA 01821 
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