Mother/Guardian First Name: 
Mother/Guardian Last Name:
                                   Address:
                                        City:        St:    Zip:   

      email Address:
         Home Phone:   Work Phone:
Mother will help with: volunteer coach/ass't coach team mgr referee league >

Emergency Contact (other than parent):  
                                                          Phone:

If you are registering 2 or more children and wish to have them on the same
divisional team, please specify other child's name. Same family only.

Player Two

Participant's First Name:   
  Participant's Last name:

                            Address:
                       City:   Canton Collinsville Canton Center North Canton  ST:   CT  Zip:  06019 06022
                                                    Phone:  

                    Date of Birth:   Month January February March April May June July August September October November December     Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000  

sex male female On a CYSA team before yes no Travel tryout? yes no

Select Grade Fall 2005 pre-school first second third forth fifth sixth seventh eighth nineth tenth eleventh twelvth other

  Specify team type Coed/Boys Girls Child lives with mother father both

Player Three

Participant's First Name:   
  Participant's Last name:

                            Address:
                       City:   Canton Collinsville Canton Center North Canton  ST:   CT  Zip:  06019 06022
                                                    Phone:  

                    Date of Birth:   Month January February March April May June July August September October November December     Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000  

sex male female On a CYSA team before yes no Travel tryout? yes no

Select Grade Fall 2005 pre-school first second third forth fifth sixth seventh eighth nineth tenth eleventh twelvth other

  Specify team type Coed/Boys Girls Child lives with mother father both

Player Four

Participant's First Name:   
  Participant's Last name:

                            Address:
                       City:   Canton Collinsville Canton Center North Canton  ST:   CT  Zip:  06019 06022
                                                    Phone:  

                    Date of Birth:   Month January February March April May June July August September October November December     Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31   Year 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000  

sex male female On a CYSA team before yes no Travel tryout? yes no

Select Grade Fall 2005 pre-school first second third forth fifth sixth seventh eighth nineth tenth eleventh twelvth other

  Specify team type Coed/Boys Girls Child lives with mother father both

To parents and guardians:
I, as parent and guardian of the above referenced child, through the submission of this form, consent to my child's participation in the Canton Youth Soccer Association program. I
recognize that in my child's participation there is risk of injury and accept that risk on my child's behalf. I agree to indemnify and hold harmless all officers of the program and their agents for any and all claims arising out of injuries or damages sustained by my child. I guarantee that I have listed my child's birth date accurately.