participant registration form - League Athletics
EASTERN PENNSYLVANIA YOUTH SOCCER ASSOCIATION, INC.
RG-6
PARTICIPANT REGISTRATION FORM Instructions for filling out this form: Print out a copy of this form. Fill it out completely and make sure it is signed by appropriate Parent(s)/Guardian(s). Mail completed form to the league Registrar.
CHECK ONE: CHECK ONE: PLAYER
TRAVEL
2 2 HEAD COACH 1 B e c k
RECREATIONAL
2 2 1 2 B 2 e 1 c B k e c k2
ASSISTANT COACH
ADMINISTRATOR
2 2 CLUB 1
TEAM PARENT/MANAGER
2 2 2 2 2 2 1 AGE DIV. U-1 B TEAM 1 B B e B FIRST LAST NAME e NAME e c e c c k c ADDRESS k k 2 k CITY STATE ZIP CODE 2 2 TOWNSHIP/BOROUGH 2 COUNTY 2 2 2 DATE 2 R 2 2 2 BIRTH MALE FEMALE R 2 2 2 2 Mo 2 2 M D D 2 Y Y 2 2 2 2o 2 2 2 2 2 THIS PLAYER BEEN 2 ROSTERED 2 IN ANOTHER US YOUTH SOCCER R ORGANIZATION IN THE22014-15 SOCCER YEAR? HAS TO A TEAM YES 2 NO 2 1 1 2 2b 2 2 2 b2 R TO THE PREVIOUS QUESTION, R o IFR YOU SELECTED YES THE PLAYER IS CONSIDERED A TRANSFER. YOURMUST PROVIDE THE FOLLOWING INFORMATION ABOUT 2 2 THE 1 B B 1 1 1 1 1 PLAYER’S ID ON THE o o PREVIOUS 2014-15 TEAM: o STATE ASSOCIATION: b o 1 2 e e B B B B B B b b ID2 b b AUTHORIZED AND COMPLETE OUT-OF-STATE PLAYER DOES THE PLAYER HAVE AN RELEASE 2 B 1 c c e e e e e e DOCUMENT FROM HIS/HER TEAM APPROVED BY THE PREVIOUS US YOUTH SOCCER STATE ASSOCIATION IN WHICH HE/SHE WAS ROSTERED? YES NO e B k k c c2 c c c 2c 2 2 YES PREVIOUS TEAM DID COMPETE IN A 2014-15 c e k k 3 STATE k 3k k CUP k COMPETITION 2 2 NO 2 2 2 K 2 2 2 K k c 1 2 2 PARENT(S) / GUARDIAN(S) NAME(S) 2 2 y 2 3 PLEASE PRINT 2 y k 2 2 2 B 2 3 3 l 3 K 3 l E-MAIL ADDRESS(ES) 2 2 1 2 2 2 2 2 2 e B 1 K K e K y K e 2 2 2 2 2 2 2 2 WORK OR c e B 2 B HOME CELL y PHONE y a ya l PHONE y 2 2 R 2 2 2 2 2 2 k c e R e l l l e l 2 2 o R R R R R R k c o c Release e e e a Statemente R 2 o by Parent/Guardian b Minor kPlayer; b ankAdult Player for him/herself; Coach for him/herself; and o MUST o o o beo signed NOTE: This statement for a a 2 a2 a o R2 Administrator for him/herself. b b b b b b 2 2 b o2 2 I, the parent/guardian of registrant, a minor or adult registrant of legal age, agree that I and the registrant will abide by the rules of Eastern 2 4 4 b 2 sponsors. 2 2 the possibility of physical injury associated with 2 soccer and 2 in 2 Recognizing Pennsylvania Youth Soccer, and its affiliated organizations and 2 2 C 2 2 2programs and activities (“the Programs”), I hereby C consideration for Eastern Pennsylvania Youth Soccer accepting the registrant for its soccer 2 2 2 2 2 2 2 2 R 2 2 2 2 2 4 Youth Soccer, its affiliated 2 organizations and sponsors, release, discharge2and/or otherwise indemnify Eastern Pennsylvania their employees and h h 2 3 3 2 2 2 2 2 2of fields 2 and facilities o R 2 for associated personnel, utilized the Programs,4against any claim by or on behalf of the registrant as a 4 4 rincluding the owners 4 C r 2 2 K transported 3 in3 the Programs, 3 participation 3 3 and/or being 3 b o R K to Ror from the same which transportation I hereby authorize result of registrant’s C C i C h C i 3 2 y K K K K K K b o y o h h OR h r PARENT/GUARDIAN ADULT SIGNATURE DATE h s s K 3 l y y y y y y b l b M M D D Y Y Eastern iPennsylvania Youth Soccer r r r r y K 2 2 2 2 2 2 l e e l Butler Pike, l l 4070 l Suite l 100 I Plymouth Meeting, PA 19462 I 610.238.9966 I www.epysa.org 2 i Rev. 3/13 i i s SOCCER FEDERATION i(USSF) AND FEDERATION l RG-6(P) AFFILIATED WITH UNITED STATES 2 2 y2 2 2 2 2 2 a a e e e e e e INTERNATIONAL DE FOOTBALL ASSOCIATION s s s s (FIFA) LEAGUE
2 2 2 1
RG-6
PARTICIPANT REGISTRATION FORM Instructions for filling out this form: Print out a copy of this form. Fill it out completely and make sure it is signed by appropriate Parent(s)/Guardian(s). Mail completed form to the league Registrar.
CHECK ONE: CHECK ONE: PLAYER
TRAVEL
2 2 HEAD COACH 1 B e c k
RECREATIONAL
2 2 1 2 B 2 e 1 c B k e c k2
ASSISTANT COACH
ADMINISTRATOR
2 2 CLUB 1
TEAM PARENT/MANAGER
2 2 2 2 2 2 1 AGE DIV. U-1 B TEAM 1 B B e B FIRST LAST NAME e NAME e c e c c k c ADDRESS k k 2 k CITY STATE ZIP CODE 2 2 TOWNSHIP/BOROUGH 2 COUNTY 2 2 2 DATE 2 R 2 2 2 BIRTH MALE FEMALE R 2 2 2 2 Mo 2 2 M D D 2 Y Y 2 2 2 2o 2 2 2 2 2 THIS PLAYER BEEN 2 ROSTERED 2 IN ANOTHER US YOUTH SOCCER R ORGANIZATION IN THE22014-15 SOCCER YEAR? HAS TO A TEAM YES 2 NO 2 1 1 2 2b 2 2 2 b2 R TO THE PREVIOUS QUESTION, R o IFR YOU SELECTED YES THE PLAYER IS CONSIDERED A TRANSFER. YOURMUST PROVIDE THE FOLLOWING INFORMATION ABOUT 2 2 THE 1 B B 1 1 1 1 1 PLAYER’S ID ON THE o o PREVIOUS 2014-15 TEAM: o STATE ASSOCIATION: b o 1 2 e e B B B B B B b b ID2 b b AUTHORIZED AND COMPLETE OUT-OF-STATE PLAYER DOES THE PLAYER HAVE AN RELEASE 2 B 1 c c e e e e e e DOCUMENT FROM HIS/HER TEAM APPROVED BY THE PREVIOUS US YOUTH SOCCER STATE ASSOCIATION IN WHICH HE/SHE WAS ROSTERED? YES NO e B k k c c2 c c c 2c 2 2 YES PREVIOUS TEAM DID COMPETE IN A 2014-15 c e k k 3 STATE k 3k k CUP k COMPETITION 2 2 NO 2 2 2 K 2 2 2 K k c 1 2 2 PARENT(S) / GUARDIAN(S) NAME(S) 2 2 y 2 3 PLEASE PRINT 2 y k 2 2 2 B 2 3 3 l 3 K 3 l E-MAIL ADDRESS(ES) 2 2 1 2 2 2 2 2 2 e B 1 K K e K y K e 2 2 2 2 2 2 2 2 WORK OR c e B 2 B HOME CELL y PHONE y a ya l PHONE y 2 2 R 2 2 2 2 2 2 k c e R e l l l e l 2 2 o R R R R R R k c o c Release e e e a Statemente R 2 o by Parent/Guardian b Minor kPlayer; b ankAdult Player for him/herself; Coach for him/herself; and o MUST o o o beo signed NOTE: This statement for a a 2 a2 a o R2 Administrator for him/herself. b b b b b b 2 2 b o2 2 I, the parent/guardian of registrant, a minor or adult registrant of legal age, agree that I and the registrant will abide by the rules of Eastern 2 4 4 b 2 sponsors. 2 2 the possibility of physical injury associated with 2 soccer and 2 in 2 Recognizing Pennsylvania Youth Soccer, and its affiliated organizations and 2 2 C 2 2 2programs and activities (“the Programs”), I hereby C consideration for Eastern Pennsylvania Youth Soccer accepting the registrant for its soccer 2 2 2 2 2 2 2 2 R 2 2 2 2 2 4 Youth Soccer, its affiliated 2 organizations and sponsors, release, discharge2and/or otherwise indemnify Eastern Pennsylvania their employees and h h 2 3 3 2 2 2 2 2 2of fields 2 and facilities o R 2 for associated personnel, utilized the Programs,4against any claim by or on behalf of the registrant as a 4 4 rincluding the owners 4 C r 2 2 K transported 3 in3 the Programs, 3 participation 3 3 and/or being 3 b o R K to Ror from the same which transportation I hereby authorize result of registrant’s C C i C h C i 3 2 y K K K K K K b o y o h h OR h r PARENT/GUARDIAN ADULT SIGNATURE DATE h s s K 3 l y y y y y y b l b M M D D Y Y Eastern iPennsylvania Youth Soccer r r r r y K 2 2 2 2 2 2 l e e l Butler Pike, l l 4070 l Suite l 100 I Plymouth Meeting, PA 19462 I 610.238.9966 I www.epysa.org 2 i Rev. 3/13 i i s SOCCER FEDERATION i(USSF) AND FEDERATION l RG-6(P) AFFILIATED WITH UNITED STATES 2 2 y2 2 2 2 2 2 a a e e e e e e INTERNATIONAL DE FOOTBALL ASSOCIATION s s s s (FIFA) LEAGUE
2 2 2 1
