KPSL PLAYER CARD REQUEST FORM

CLUB: *

TEAM NAME: *

COACH: *

TEAM MANAGER:

AGE GROUP: *

GENDER: *

CONTACT NAME: *

First Name Last Name

CONTACT PHONE: *

Please enter a valid phone number.

CONTACT EMAIL: *

example@example.com

Player / Coach Passes:
No player/coach/administrator passes can be issued without payment.
No coaches / administrator cards can be issued without prior approved background check completion.

KANSAS COACH'S RISK MANAGEMENT POLICY & SAFESPORT

Please review the KSYSA Risk Management & SafeSport policies at the following link:

https://www.kansasyouthsoccer.org/coaching/safesoccer/

Risk Management Background checks are done through KSYSA & GotSoccer, not KPSL.

Player Passes:

$16.75 x # of players

Total Player Passes:

Secondary/Trfr Passes:

$7.50 x # of players

Total Secondary/Transfer Passes:

If the player card is for a transfer player - has the player release form been

Submitted Approved

Kansas State Player Release bylaws can be found here:

https://www.kansasyouthsoccer.org/players/releasetransfer/

The player release form is an online form and can be found here:

https://www.gotsport.com/forms/open/Default.asp?FormID=1365

Coaches/Mgr Passes:

$7.50 x # of players

Total Coaches/Manager Passes:

Replacement Cards:

$5.00 x # of players

Total Replacement Cards:

TOTAL DUE:

PLAYER CARDS: Please complete information below for each player being added to your team. ALL FIELDS ARE REQUIRED.

Last Name

First Name

Birth Date

Jersey #

P / S

Transfer?

Email

1

2

3

4

5

COACHES & MANAGERS: Please complete information below for each Coach or Manager being added to your team. ALL FIELDS ARE REQUIRED.

Last Name

First Name

Birth Date

Coach / Manager

Email

1

2

3

4

ECHECK PAYMENT AUTHORIZATION:
I, blanks , authorize KPSL to charge my on Date for the amount of for Team Roster & Player/Coach registration and carding. My account information is as follows:

eCheck Payment - All Fields Required:

USD

eCheck.Net
Bank Account Type
Routing Number	Account Number
Name On Account	Bank Name

This payment authorization is valid and to remain in effect unless I, blanks , notify KPSL of its cancellation by sending written notice.

Please document any details the Registrar should know to help with rostering and carding the player(s):

KPSL Registrar: Sheila Ozburn
Email: registrar@kpsl.org
KPSL Address: 10529 South Warwick St.
Olathe, KS 66061