East Millard Recreation
             
East Millard Recreation
Youth Soccer League

Should you have questions please contact Brenden Turner.
435-253-1047 or bturner@co.millard.ut.us

Season begins on August 5th - Two games per week!

Participant MUST be 4 years old as of July 31, 2024
 
Parent/Guardian Information
First Name: Last Name:
Address:
Address:
City: State/Province: ZIP/Postal Code:
Phone:
Email:
 
Emergency Contact Full Name (other than parents)
Emergency Contact Phone Number
Are you willing to Coach?
Are you willing to Assistant Coach?
I can help Referee
 
Soccer Registration:   $40.00   Quantity:   Item Subtotal:  
$40.00
Participant's Full Name (First | Last) [1]
Participants Date of Birth [1]
Participants Age [1]
Participants Grade for the 2024-2025 year [1]
Participants Jersey Size [1]

Participant's Full Name (First | Last)

[2]
Participants Date of Birth [2]
Participants Age [2]
Participants Grade for the 2024-2025 year [2]
Participants Jersey Size [2]

Participant's Full Name (First | Last)

[3]
Participants Date of Birth [3]
Participants Age [3]
Participants Grade for the 2024-2025 year [3]
Participants Jersey Size [3]

Participant's Full Name (First | Last)

[4]
Participants Date of Birth [4]
Participants Age [4]
Participants Grade for the 2024-2025 year [4]
Participants Jersey Size [4]

Participant's Full Name (First | Last)

[5]
Participants Date of Birth [5]
Participants Age [5]
Participants Grade for the 2024-2025 year [5]
Participants Jersey Size [5]

Participant's Full Name (First | Last)

[6]
Participants Date of Birth [6]
Participants Age [6]
Participants Grade for the 2024-2025 year [6]
Participants Jersey Size [6]

Participant's Full Name (First | Last)

[7]
Participants Date of Birth [7]
Participants Age [7]
Participants Grade for the 2024-2025 year [7]
Participants Jersey Size [7]

Participant's Full Name (First | Last)

[8]
Participants Date of Birth [8]
Participants Age [8]
Participants Grade for the 2024-2025 year [8]
Participants Jersey Size [8]

Participant's Full Name (First | Last)

[9]
Participants Date of Birth [9]
Participants Age [9]
Participants Grade for the 2024-2025 year [9]
Participants Jersey Size [9]

Participant's Full Name (First | Last)

[10]
Participants Date of Birth [10]
Participants Age [10]
Participants Grade for the 2024-2025 year [10]
Participants Jersey Size [10]
 
Please describe any physical or other limitations participant(s) may have.
 
Total:
$40.00

This consent is for the 2024 Year. My child/children listed above is/are physically fit & otherwise able to participate in this program. I understand the program will be supervised and I further understand Millard County Recreation and its employees will not be held liable for any accidental injury incurred while my child/children is participating or while they are transported to and from games. I authorize emergency treatment to the above named participants for any accident or illness & consent to allow East Millard Recreation and their volunteers to use their discretion in approving medical care.

I UNDERSTAND THAT IT IS MY OBLIGATION & RESPONSIBILITY TO PROVIDE MEDICAL INSURANCE COVERAGE FOR ANY INJURY SUSTAINED WHILE PARTICIPATING IN THIS PROGRAM.

I agree
I have read and agree to the statement above.
Payment Information:
Processing Fee Rates:
Cards:2.5% ($1.50 min)
(1.5% surcharge for foreign cards)
eCheck:$0.50
Method of Payment:
  Credit/Debit Card
  eCheck
 Update Name from Above
Name on Account:
Routing Number:
Account Number:
Institution:
Name on Card:
Account Number:
Expiration Date:
Billing Street Address:
Billing ZIP/Postal Code:
 Change Payment Method
Your statement will describe your payment as CBT*MILLARD COUNTY UT
and the service fee transaction as CBT*SVC FEE MILLARD C
Submitting ...