2014 FALL SOCCER REGISTRATION

IRVSA
P.O. BOX 409
SENECA, ILLINOIS 61360
Mail to:

www.facebook.com/senecayouthsoccer
Sign-up Dates: Sat. June 7 10am-1pm, Tue. June 10 5-8pm & Sat. June 14 10am-1pm at the Manlius Township Building.

DEADLINE to register is June 14, 2014. Late registration accepted until June 30, 2014.
PLAYER NAME:________________________________________
PHONE:______________________________________________
ADDRESS:____________________________________________
TOWN:________________________________ ZIP:___________

Jersey

UNIFORM
SIZES Short
YXS (4)
YS (5)

AGE:______ on 7/31/2014
BIRTHDATE:_____/______/______
MUST PROVIDE A COPY OF BIRTH CERTIFICATE

GENDER:

MALE

FEMALE

YM (6/8)
MOTHER/GUARDIAN:___________________________________
CELL:________________________________________________
EMAIL:_______________________________________________
FATHER/GUARDIAN:____________________________________
CELL:________________________________________________
EMAIL:_______________________________________________
EMERGENCY CONTACT:_________________________________
PHONE:______________________________________________
DOCTOR:_____________________________________________
PHONE:______________________________________________
MEDICAL CONDITION:__________________________________
____________________________________________________

YL (10/12)
AS (28)
AM (32)
AL (38)
AXL (40)
AXXL (42)

I would like to be a:
Coach
Assistant Coach
Referee
Sponsor
Board Member
A IRVSA Board Member
will contact you

Please put the following sibling on this player's team:

$25 U6 Dribbler
4 / 5 year old
$35 U8 Passer
6 / 7 year old
$50 U10 Wing
8 / 9 year old

Field Helper
ADDITIONAL COMMENTS:_______________________________
_____________________________________________________
_____________________________________________________
_____________________________________________________

DIVISIONS / FEES select one

as of player's age on 7/31/2014

$60 U12 Striker

10 / 11 year old
$60 U14 Kicker
12 / 13 year old
$60 U19 Senior - Female Only
14 / 15 / 16 / 17 / 18 year old
Add $10.00 late fee after June 14, 2014
Make check payable to: IRVSA
A $25 fee will be charged for NSF checks

_____________________________________________________
Same division only

We hereby agree that the Soccer Association for Youth (SAY), it's members, coaches
or officers shall not be liable for any injury or loss which my child may sustain while
participating in activities of any kind while sponsored by or under the supervision of SAY
and we agree to indemnify and hold harmless SAY, it's members, coaches, officers or
designates of any kind from any claim whatsoever. We hereby give permission for
emergency medical treatment of our child for illness or accident if we cannot first be
contacted. We hereby consent that photo images of our child may be shown on the IRVSA
Facebook page, used for IRVSA advertising or newspaper releases. We have read the IRVSA
"0" Tolerance Policy.
Parent/Guardian Signature:____________________________________ Date:____________

CHALLENGER SPORTS
BRITISH SOCCER CAMP
Seneca South Campus
Monday, July 7 thru July 11
Ages 3-6 5pm-6:30pm each day
Ages 7-18 5pm-8pm each day
COACHES CAMP
Saturday, July 12
9am-10:30am
Sign-up Forms will be available
at area schools March 31, 2014

for ILLINOIS RIVER VALLEY SOCCER ASSOCIATION USE ONLY

Fee(s)

Registration Signed

Birth Certificate

Proof of Residency

Discount

Board Member Signature:________________________________________ Date:_____________

Cash

Check#:____________

Amount Paid: $________________