Registration Form Player Name

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Burgettstown Area Youth Soccer Association

c/o Ron Osborn

PO Box 239

Langeloth, PA 15054

                       2010 Fall Registration Form

Player Name:                                                  

Gender: M/F

Age:                Birthdate:                          School:                       




City:                                                 State:               Zip:               



Emergency Contacts:                                                               


Relationship to Player:                                                     

           U6 8/1/2004 to 7/31/2006                   ______U12 8/1/1998 to 7/31/2000

______U8 8/1/2002 to 7/31/2004                ______U14 8/1/1996 to 7/31/1998

______U10 8/1/2000 to 7/31/2002 ______U15 8/1/1995 to 7/31/1996
Some divisions may need to be combined.

Cost/Player: $40.00/player - $ 110.00/family of 3 or more (payment is required at time of registration)-Make checks payable to BAYSA.

Injury Waiver: I recognize and understand that soccer is a sport involving risks not encountered in everyday play. with the understanding, in consideration of BAYSA permitting my child to participate in their soccer program, I covenant and agree to indemnify and hold harmless and do release, requite and forever discharge BAYSA, its Officers, coaches, referees and other such volunteers as are connected with BAYSA in any capacity, for any and all damages, claims and/or liabilities arising out of any and all injury to or caused my child. With the knowledge and understanding of the foregoing, this is to certify that my child has my permission to play soccer in the BAYSA program.

Parent/Guardian Signature:                                             Date:                      

Medical Consent: I hereby authorize any and all emergency medical treatment deemed necessary for my child by a physician, nurse or paramedic. A copy of this authorization shall be as effective as the original.

Parent/Guardian Signature:                                              Date:                     

Website Photo Consent: I do hereby agree to allow my child’s photo to be taken, obtained and used on the BAYSA website without compensation to me or my child. I understand that my child's name will not be listed with any of the photos displayed on the BAYSA website.

Parent/Guardian Signature:                                              Date:                        

BAYSA IS A VOLUNTEER ORGANIZATION.  All activities require volunteers.  Each family will be assigned a concession shift.  Please check below all other areas where you can help to keep our organization running:

______Coach                          ______Field Line Painting -                                                                                  Before Sat. Games

______Asst. Coach          ______Field Cleanup & Trash Disposal -                                                             After Sat. Games

______Occasionally Available; Contact to Ask For Help

Volunteers 18 and over who have regular contact with minors are required to have a current PA West Soccer background check, OR must provide a current Act 33/34 clearance.  Background checks are not required for occasional volunteers.  BAYSA will provide information on how to get a PA West Soccer background check, and will reimburse the background check fee with proof of payment.


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