2012 Anna Recreational Fall Soccer Registration
U6 & U8 Ages 4 – 7 (on July 31, 2012)
Sponsored by the Anna Rocket Athletic Boosters
Please complete the form below and return it with your payment
to the Elementary or Middle school office, open registration or
mail to:
Anna Youth Soccer
Anna Elementary School
P.O. Box 169
Anna, Oh 45302
Open Registration
Anna Elementary School
May 8, 2012
3:30 – 6:00
Volunteers Needed
This soccer program is 100% dependent on volunteers! If
you are able to get more involved please indicate below.
***There is no experience necessary to coach. We offer
training courses and resources.
Coach
A form must be completed for each child and both sides
completed. The forms and payment need to be turned in by
May 11, 2012.
Office Use Only
Please circle preference: I would like to
Asst. Coach
Referee
Fields Pictures
Name:_________________________
Website: www.leaguelineup.com/annasoccer
Contact Information: Email: annayouthsoccer@yahoo.com
Director: Lisa McEldowney 937-216-4159
Nicole Gannon 937-626-5149
Coaches will contact team members at the end of July
Contact Info:____________________________________
T-shirt Size if coaching: S
(Circle One)
M L XL XXL XXXL
Player Name:
Age on July 31st
Must be
4, 5, 6, or 7 yrs old
Birthday
Grade
Fall 2012
Gender
Parents Email address
Experience Level
New Player
__/__/__
Mo
Day
Played at least 1 yr
Year
Shirt Size (Circle One)
Youth YS YM YL
Adult AS AM AL AXL
Wants to be on the same team as brother / sister /
carpool
(Not Guaranteed)
Name: __________________________
The Fees for all soccer teams and age groups are:
Booster Member
Non Member
First Child
$35.00
$45.00
Each addt’l child $30.00
$40.00
Make checks payable to: Rocket Athletic Boosters
Booster Member
Non Member
If you would like to join or renew your Rocket Athletic
Boosters Membership and take full advantage of the
Booster member discount, please add your $25.00
membership dues below. You may write one check
for sign-ups and membership fees.
Example
First Child
$35.00
2nd Child
$30.00
TOTAL
Amount Enclosed
$ _________________
3rd Child
Booster Membership
Office Use Only
$25.00
$90.00
Cash
Check #________
I would like my child to play in the Anna Youth Soccer program in the Fall of 2012. I will not hold the Anna Local
Schools, Rocket Athletic Boosters, coaches or any assistant coach responsible for any accidents or injuries that
occur while participating in this program
PARENT SIGNATURE___________________________________________________
DATE _______________
EMERGENCY MEDICAL AUTHORIZATION FORM
Purpose: To enable parents and guardians to authorize the provision of emergency treatment for children
who become ill or injured while participating in the Rocket Athletic Booster Fall Soccer Program.
Player Information
Last Name:
First Name:
Street Address:
City:
State:
Zip Code:
We will be using One Call Now
again this year to relay valuable
information. Please designate up
to two phone numbers below that
you would like to have called.
Mother / Guardian Name:
Home phone #:
Cell Phone #:
Work Phone #:
Father / Guardian Name:
May child be given Tylenol or
Advil (check one):
Yes
No
Home phone #:
Cell Phone #:
Work Phone #:
Emergency Contact Name:
Home phone #:
Cell Phone #:
PART 1 OR PART 2 MUST BE COMPLETED
Part 1 I HEREBY CONSENT FOR THE FOLLOWING MEDICAL CARE PROVIDERS AND LOCAL HOSPITAL TO BE CALLED:
Physician:
Phone:
Dentist:
Phone:
Hospital:
Phone:
Allergies
Medications being taken:
In the event reasonable attempts to contact me have been unsuccessful, I hereby give consent for: 1) the administration of any treatment
deemed necessary by above-named doctors, or in the event the designated practitioner is not available, by another licensed physician or
dentist: and 2) the transfer of the child to any hospital reasonably accessible. This authorization does not cover major surgery unless the
medical opinions of two other licensed physicians or dentist concurring in the necessity for such surgery are obtained prior to the
performance of such surgery: Facts concerning the child’s medical history, including allergies, medications being taken, and impairments to
which a physician should be alerted are noted above.
SIGNATURE OF PARENT/GUARDIAN:____________________________________________DATE:______________________
PART 2 REFUSAL TO CONSENT: I do not give consent for emergency medical treatment of my child. In the event of illness or
injury requiring emergency treatment, I with the proper authorities to take the following action____________________________________
SIGNATURE OF PARENT/GUARDIAN:________________________________________________________DATE_____/_____/_____