LAST NAME                      FIRST NAME                         PROGRAM CODE                DATE OF BIRTH                   GRADE

Child #1              ______________               ______________                   ______________                    ______________                    ______________

Child #2              ______________               ______________                   ______________                    ______________                    ______________

Child #3              ______________               ______________                   ______________                    ______________                    ______________

Child #4              ______________               ______________                   ______________                    ______________                    ______________

 

Address  ____________________________________________________        Town/Zip Code _________________

 

Mother’s Name _____________________________________________         Phone # _______________________

Address (if different than above) _________________________________________________________________

Email address _______________________________________________         Work Phone ___________________

 

Father’s Name ______________________________________________         Phone # _______________________

Address (if different than above) ________________________________________________________________

Email address ______________________________________________           Work Phone ___________________

 

Emergency Contact _________________________________________           Phone # _______________________

 

Did child play last year? (Circle)                Child #1 yes/no                 Child #2 yes/no                   Child #3 yes/no              Child #4 yes/no

Trying out for travel? (Circle)                     Child #1 yes/no                 Child #2 yes/no                   Child #3 yes/no              Child #4 yes/no

 

If parent is interesting in volunteering, circle interests:

 

League coordinator                                             Assistant coach                                Coach                                     Parent Liaison (Biddy only)

 

Conflict night (night that child can not practice due to other conflicts; do not include soccer)

Child # and night __________________________________________________________________________________________________________

 

Medical information

 

Child #1 Allergies ______________________________________________    Medical Restrictions _______________________________________

Child #2 Allergies ______________________________________________    Medical Restrictions _______________________________________

Child #3 Allergies ______________________________________________    Medical Restrictions _______________________________________

Child #4 Allergies ______________________________________________    Medical Restrictions _______________________________________

 

Other information (please include car pool requirements, which are only supported through Grade 4)

___________________________________________________________________________________________________________________________

 

Make checks payable to NYBA, Inc. Mail to P.O. Box 196, Newtown, 06470