Newfields Youth Athletic Association - (Newfields, NH)

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2023 Fall Soccer Registration - Please register by June 16th

PLAYER INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Grade:

* Age:

* Date of Birth:

* Email:

* Gender:

PARENT/GUARDIAN NAMES

* Firstname:

* Lastname:

* EMail:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Child's Physician:

* Address:

* Phone:

* Allergies:

* Medications:

Other:

WAIVER INFORMATION

I/we agree with the above *

I authorize any of my child's coaches or other league representatives, in the absence of myself or other legal guardians, to seek medical attention for my child. This can include, but is not limited to, x-ray examination, anesthetic, medical or surgical diagnosis and treatment if deemed necessary. Such care may be rendered to the minor, at a recognized facility, under the general or special supervision of a licensed physician or surgeon.

Check Here if you accept the above statement

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