form

Player Name *

First Name Last Name

Player Date of Birth *

Date

Address *

Street Address

Street Address Line 2

City

Postal / Zip Code Country

Parent Name | Guardian *

First Name Last Name

Cell Phone *

Area Code Phone Number

E-mail *

Please type the Coach Name of your Team: *

Emergency Contact

Emergency Contact's Name *

First Name Last Name

Relationship *

Phone Number *

Area Code Phone Number

Do you have health insurance ?

Yes No

Does you have any allergies, chronic illness, or medical conditions that would limit high level activtiy? *

Yes No

Please describe *

Parental Permission For Emergency Treatment

I, the parent/guardian of the above-named player, a minor, agree that I, and the player will abide by the rules and regulations of the USYSA, its affiliated organizations and its sponsors ("USYSA Parties"). Inconsideration of the player's participation in the soccer programs and activities of the USYSA Parties ("the Programs"), I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the USYSA Parties, the owners and operators of the facilities used for the Programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player's participation in the Programs including, without limitation, player's transportation to/from any Program, which transportation is hereby authorized.

I have read and agree to the above conditions *

Yes No

Confirmation E-mail *

Signature *

Clear

After completing this form, please make payment below and click Submit Form. If you do not make the payment, registration will not be received, player will not be registered to the team and player card will not be issue by US Youth Soccer Association | Arizona Soccer Association.

Registration *

Season Registration $ 185.00

Total $ 0.00

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Credit Card Number	Security Code
Expiration Date	Postal Code

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