JONATHAN ALDER SOCCER ASSOCIATION (JASA) REGISTRATION       #
CHILD’S NAME _________________________________________  PHONE ___________________      
ADDRESS _______________________________________CITY ______________ ZIP ___________
MALE OR FEMALE         DATE OF BIRTH ___________________AGE _______   GRADE _______
WHAT SCHOOL ATTENDING? _______________________ 
EMAIL ADDRESS: __________________________________________
DID CHILD PLAY LAST SEASON?   YES  OR NO               IF YES:    SPRING   OR   FALL
IF YES:  WHAT DIVISION_________________ WHAT TEAM_______________
UNIFORM NEEDED:  Y OR N   SHIRT SIZE:   YS   YM   YL   AS   AM   AL   
       SHORTS SIZE:  YS   YM   YL   AS   AM   AL
NAMES/AGES OF BROTHERS/SISTERS PARTICIPATING THIS SEASON:___________________________
Please be aware that if the child decides not to play prior to the start of the season, there will be a $5.00 charge for withdrawing.    Please initial here that you have read this. _________________
LIABILITY RELEASE
DOES YOUR CHILD HAVE ANY SPECIAL NEEDS LIMITING HIS/HER SPORTS ACTIVITY?  _________
IF SO, PLEASE DESCRIBE ___________________________________________________________
___________________________HAS MY PERMISSION TO PARTICIPATE IN THIS JASA SPORTS PROGRAM.  IN THE EVENT THAT HE/SHE IS INJURED, JASA HAS MY PERMISSION TO SEEK NECESSARY MEDICAL ATTENTION.  I WILL NOT HOLD JASA OR ITS REPRESENTATIVES LIABLE.   IN ADDITION, THE UNDERSIGNED PARENT OR LEGAL GUARDIAN OF THE CHILD NAMED ABOVE (“PARTICIPANT”) FOR HIS OR HERSELF AND ON BEHALF OF THE PARTICIPANT HEREBY ASSUMES THE RISK FOR ANY INJURIES THAT PARTICIPANT MAY SUSTAIN WHILE ENGAGED IN, OR IN PURSUIT OF, ANY ACTIVITIES WHILE ON THE PREMISES LOCATED AT 8690 US 42, PLAIN CITY, OHIO (THE “PREMISES”) AND, PARTICIPANT HEREBY INDEMNIFIES AND RELEASES THE OWNER OF SAID PREMISES, THE DUTCH CORPORATION, ITS AGENTS, SUCCESSORS AND ASSIGNS, FROM ALL LIABILITY FOR PERSONAL INJURY (INCLUDING WRONGFUL DEATH) OR PROPERTY DAMAGE SUFFERED BY PARTICIPANT WHICH IS CAUSED, IN WHOLE OR IN PART, BY ANY ACTIVITY OR CONDITION ON THE PREMISES.   
SIGNED __________________________________RELATIONSHIP____________________DATE__________
IN CASE OF EMERGENCY NOTIFY _________________________________PHONE___________________
The success of our program depends on parents and volunteers.  Please circle the area you would be willing to help. 
COACHING	  REFEREE	CONCESSIONS	FIELD MAINTENANCE	ADMINISTRATIVE
COMMISSIONERS USE ONLY
DATE PAID:____________________CASH/CHECK :_________________AMOUNT: __________________    
UNIFORM:      YES          NO          SHIRT           SHORTS           SOCKS      
DIVISION: ________________________		TEAM: __________________________