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 OR JONATHAN ALDER SCHOOLS OR ITS REPRESENTATIVES LIABLE. SIGNED __________________________________RELATIONSHIP____________________DATE__________ IN CASE OF EMERGENCY NOTIFY _________________________________PHONE___________________ The success of our program depends parents and volunteers. Please help by circling the area you would be willing to help in. COACHING REFEREE CONCESSIONS FIELD MAINTENANCE ADMINISTRATIVE COMMISSIONERS USE ONLY DATE PAID:____________________ CASH/CHECK :_________________ AMOUNT: __________________ UNIFORM: YES NO SHIRT SHORTS SOCKS DIVISION: ________________________ TEAM: __________________________