AYSL- Indoor Soccer- the futsal experience
Registration: Fee $70
Mail to:
Dragons Soccer
100 Dewey Street
Ashland, VA 23005
Please indicate which division:
I (U6-U-7)
II (U8-U9)
III (U10-U11) IV (U12-U14) V (U15-U18)
Adult- 35+
Player
Name: ______________
Age: ___
Gender: _________
Birth date: ___________
Seasons Experience: ____
Club Association: _____
School: _______________
Home phone: _______________
Parent
Mother: ____________
Cell phone: ____________
E-mail: _______________
Address: __________________
Father: ______________
Cell phone: ________________
E-mail: __________________
Address: _______________
Team or Coach Request ______________________________
Emergency Information
Hospital: _____________ Doctor: _______________
Insurance Provider: ____________ Policy Number: ____________
Medical Concerns and/or
issues that can help us provide proper emergency care for your child _______________________________________________________________
________________________________________________________________________
In the event of an emergency situation, I give the AYSL, emergency personnel, and anyone associated
with the indoor soccer league to follow emergency procedures as deemed necessary by the first aid provider or emergency personnel.
(Please sign, date, and print)
____________________ ________ ____________________
Signature
date
print
Emergency Contact
Name: ______________________________________________________________
Home phone: _________________________________________________________
Cell phone: __________________________________________________________ 