Registration Costs:

$110if received by 10/31/16

$140for all registrations received after
10/31/16.
*Teams will be formed with registrations
received by 12/31/16.

Player Informationfor participation in the Buffalo Western New York Junior Soccer League
(to be eligible, players must be at least 8 years of age by 1/1/2017)

Player Name: ____________________________________Player Birthdate: _____________

Player Grade (2016-2017 school year) _____________ Male: ________ Female: _________

Have you played with us before?: Y or N If yes, jersey number? ______________

(if no, please include a copy of your birth certificate with registration)

Player Telephone: __________________ Player email: _____________________________

Best method of contact?: phone call or phone text or email
Player Address: _______________________________________________________________
_______________________________________________________________
Parent(s) Name(s): ____________________________________________________________
Parent Phone/Email (if different from above): ______________________________________
______________________________________________________________________________
Person to Notify in Case of Emergency: _____________________________ ph: _____________________
Medical Restrictions (if any): ________________________________________________________________

Parent/Guardian Release and Consent for Medical Treatment: I, _____________________________________, the parent/guardian of the
above named player do agree to abide by the rules of the Holland Soccer Club, its affiliated organizations and sponsors. Recognizing the possi-
bility of physical injury during play and in consideration for the Holland Soccer Club, I hereby release, discharge and/or otherwise indemnify the
Holland Soccer Club, its affiliated organizations and sponsors, their employees and associated personnel, including but not limited to the owners,
lessors, lessees of fields and facilities utilized for any soccer related activity during the course of this season, against any claim by or on behalf of
the player as a result of the players participation in any club sponsored activity and/or being transported to or from the same, which transportation
I hereby authorize.
As the parent or legal guardian of the above named 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 the life, limb or well-being
of my dependent, the player.
Parent/Guardian Name (print): ___________________________________________________________________
Signature: _________________________________________________________ Date: _______________________
Please mail completed registrations and payment to: Holland Soccer Club * PO Box 321 * Holland, New York 14080

For Office use Only: Registration received payment received birth certificate received
Date: _____________ check no: _______ team: U______ coach: _____________