Form

Check One

Travel Recreational

Check One

Player Head Coach Assistant Coach Administrator Team Parent/Manager

League

Club

Team Age Division U- *

Team

Coach

First Name *

Last Name *

Address *

City *

State *

Zip Code *

Township/Borough *

County *

Birthdate MM-DD-YY *

Gender *

Male Female

Has this player been rostered to a team in another US Youth Soccer Organization in the 2018-2019 soccer year? *

Yes No

If you selected YES to the previous question, the player is considered a transfer. You must provide the following information:

State Association

Out of State Player ID

Does the player have an authorized and complete release document from his/her previous team approved by the previous US Youth Soccer State Association where he/she was rostered?

Yes No

Previous Team DID compete in the 2014-15 State Cup competition?

Yes No

Parent(s)/Guardian Name *

Email Address(es) *

Home Phone *

Work or Cell Phone *

RELEASE STATEMENT

Note: This statement MUST be signed by Parent/Guardian for minor player, an adult player for him/herself, Coach for him/herself, and/or an Administrator for him/herself.

By checking this box: I, the parent/guardian of registrant, a minor or adult registrant of legel age, agree that I and the registrant will abide by the rules of EPYSA, and its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for EPYSA accepting the registrant for its soccer programs and activities ("the Programs"), I hereby release, discharge, and/or otherwise indemnify EPYSA, it's affiliated organizations and sponsors, their employees and associated personnel, including the owners of the fields and facilities utilized for the Programs, against any claim by or on behalf of the registrant as a result of registrant's participation in the Programs, and/or being transported to or from the same which transportation I hereby authorize *

I agree to all

Parent/Guardian who completed this form *

Date MM-DD-YY *

Picture

Birth Certificate

RG6