DERBY YOUTH SOCCER - 2017 - SEASON REGISTRATION

Derby Youth Soccer will conduct a two season registration similar to the recently completed 2016 campaign.
The Spring 2017 season will start in late March/early April and end in late June.
The Fall 2017 season will start in late August/early September and end in late October/early November.
Our annual banquet will follow.

The children will be assigned to a team and given a tee shirt for both seasons [you will need to provide shin
guards, socks to cover the shin guards, cleats, soccer ball, ( # 4 for div. I-II & III and # 5 for div. IV), and
additional tee shirt if needed].
No one will be allowed to play without proper equipment and a team tee shirt.

Boys and girls born on or between January 01, 2003 and December 31, 2012 will be eligible to register to play.

You may elect to participate in one or the other or both seasons

The two-season registration fee is $30.00 each for the first two children and $20.00 for each additional child.
The fee for each half season is $20.00 per child.

Refunds for Full or Spring season will not be made after March 30-2017.
Refunds for Fall season will not be made after August 01 2017.

ALL NEW REGISTRATIONS must be accompanied with a copy of the childs birth certificate.

Please mail the form, by 28-February-2017, to: Mario Tessitore, 440 Peck Lane, Orange, CT.06477.
Payment must be made by check or money order made payable to Derby Youth Soccer.

Late registrations will be accepted based on roster availability.

Our League is composed of FOUR divisions based upon enrollment, ages, experience and ability.
All participants will receive free admission to our annual banquet.

As always, our volunteers strive to insure the safety of your children and that they have fun playing one of the
best sports in the world.

For information or questions, call Mario Tessitore, Director, at 298-9490, Farhad Mekael, Asst. Director, at 231-3321

SPONSOR(we need sponsors), As you know sponsors play a vital part in our program.
So if you or if you know someone that would like sponsor a team (cost is $ 175 per year)
Let us know by calling Chantal at 734-0330 or fill in the name and the phone # below;

Sponsor Name____________________________ Phone # _____________

PARENTAL SUPPORT(we are in need of coaches), coaches are always needed. No soccer experience
needed, but pleasant demeanors preferred. Anyone wishing to help out will be greatly appreciated and
assistance will be given.
Your Name___________________________ Phone # ______________

Your continued cooperation and support of our league is very much appreciated.
Please no special request

See opposite side for the registration form

 New Player
IN-HOUSE REGISTRATION (recreational)
2017
Returning Player
Please print all the information clearly

ALL NOTIFICATION IS VIA E-MAIL, PLEASE PROVIDE YOUR EMAIL
Transfer
Make All Checks Payable to:
Change/Correction
Derby Youth Soccer
E-Mail address...
Check one
Mail Registration Form to:
Spring and Fall ($30.00 each for the first 2 children, $20.00 for the third and up)
Mario Tessitore, Pr esident Mario Tessitore, President
50 Emmett Avenu e . Spring Only (S20.00)
Derby Youth Soccer
.... Fall Only ($20.00)
Derby, CT 06418
Tel ephon e: 203.732.4679 50 Emmett Avenue
Affiliated With:
Paid $. Check
Derby, CT or M/O #.
06418
Connecticut Junior S occer Associ ation (C JSA ) Mail to: Mario Tessitore, 440 Peck Lane., Orange, CT. 06477 (one form per player)
United States Youth Soccer Associ ation (USYSA ) (See Back Page for Additional Instruction)
United States Soccer F eder ation (USSF)
Feder ation Intern ation ale de F ootball Ass ociation (F IF A)
..(Init.) I give
Visit DYS permission for my childs
on the Web: picture, moving pictures, or any other graphic depiction or
http://www.eteamz.com/DerbyYouthSoccer/
likeness, to used by Derby Youth Soccer

LAST NAME FIRST NAME MIDDLE INITIAL

STREET ADDRESS CITY

MALE PLAYER

STATE ZIP CODE TELEPHONE DATE OF BIRTH FEMALE COACH

SEASONS PLAYED LAST TEAM PLAYED LAST LEAGUE PLAYED DATE LAST PLAYED

FATHERS NAME BUSINESS TELEPHONE MOTHERS NAME BUSINESS TELEPHONE

EMERGENCY NOTIFICATION (NAME/TELEPHONE) DOCTOR NOTIFICATION (NAME/TELEPHONE)

IMPORTANT CONSENT FOR MEDICAL TREATMENT (MINOR)

I, the parent/guardian of the registrant, a minor, agree that I and the reg-
istrant will abide by the rules of the USYSA, its affiliated organizations and
sponsors. Recognizing the possibility of physical injury associated with
soccer and in consideration for the USYSA accepting the registrant for the
soccer programs and activities (the Programs), I hereby release, dis-
charge and/or otherwise identify the owners of fields and facilities utilized
for the Programs, against any claim by or on behalf of the registrant as a
result of the registrants participation in the Programs and/or being trans-
ported to or from the same, which transportation I hereby authorize.
As the parent or legal guardian of the above named player, I hereby fie
consent for emergency medical care prescribed by a duly licensed Doctor
of Medicine or Doctor of Dentistry. The
care may be given under whatever conditions are necessary to preserve
the life, limb or well-being of my dependent.
SIGNATURE OF PARENT OR GUARDIAN

STREET ADDRESS
PRINTED NAME OF PARENT OR GUARDIAN

CITY STATE ZIP CODE

SIGNATURE DATE

PARENTAL SUPPORT From time to time, Derby Youth Soccer is asked to pro-
We ask for active participation of all parents in our pro- vide contact information from other soccer organiza-
gram. Check areas in which you would be willing to tions. These requests are usually related to soccer
help: camps, professional games and other soccer related so-
licitations and announcements. If you authorize DYS to
Coach Committee Help release your contact information for these purposes,
Assistant Coach Referee please show your authorization with your signature be-
Team Manager Fund Raising low:
Board Member Special Projects
____________________________________________