Financial Assistance Form

Family Name *

Address *

City, State, Zip *

Phone Number *

Email Address

Player Name Needing Assitance * Please list each child's name and Date of Birth

Amount of assistance being requested * Intown U5-U14 fees $95 ~ Travel fees $105

25%
50%
75%
Other:

Have you applied for financial assistance in the past *

Yes
No

For Your Information

Mansfield Youth Soccer is committed to protecting the privacy of your personal information. This privacy statement applies to all financial assistance applicants and their families. Mansfield Youth soccer does not share or disclose any of the information included in this form. Only the Registrar, Treasurer, President and Vice President are privy to this information.

Parent/Guardian's Authorization to Participate and Consent for Medical Treatment

I, the parent/guardian of the registrant, a minor, agree that the registrant and I 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 of the USYSA accepting the registrant for its soccer programs and activities (the”Programs”), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of fields and facilities utilized for the Programs, against any claim by or on the behalf of the registrant as a result of the registrant’s participation in the Programs and/or being transported to or from the same, which transportation I hereby authorize. As Parent or Legal Guardian of the above-named player, I further hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve life, limb, or well being of my dependent. My signature below signifies my agreement to abide by the aforementioned statements regarding the registrant’s participation in USYSA soccer programs:

Parent "Signature" *