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
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RECREATIONAL
2
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ASSISTANT COACH
ADMINISTRATOR
2
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CLUB
1
TEAM PARENT/MANAGER
2
2
2
2
2
2
1 AGE DIV. U-1
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TEAM
1
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FIRST
LAST NAME
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ADDRESS
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CITY
STATE
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TOWNSHIP/BOROUGH
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2
2
2 DATE 2 R
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BIRTH
MALE
FEMALE
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2 Mo
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2 2o 2 2
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2 THIS PLAYER BEEN
2 ROSTERED
2 IN ANOTHER US YOUTH SOCCER
R ORGANIZATION IN THE22015-16 SOCCER YEAR?
HAS
TO A TEAM
YES 2 NO 2
1
1
2 2b 2 2
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R TO THE PREVIOUS QUESTION,
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IFR
YOU SELECTED YES
THE PLAYER IS CONSIDERED
A TRANSFER. YOURMUST PROVIDE THE FOLLOWING INFORMATION
ABOUT
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PLAYER’S
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b AUTHORIZED AND COMPLETE
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DOCUMENT FROM HIS/HER
TEAM
APPROVED
BY
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IN
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PARENT(S)
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o MUST
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NOTE: This statement
for
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Administrator for him/herself.
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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
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4 Youth Soccer, its affiliated
2 organizations and sponsors,
release,
discharge2and/or
otherwise indemnify
Eastern Pennsylvania
their employees and
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2
3
3 2
2 2
2 2
2of fields
2 and facilities
o
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2 for
associated
personnel,
utilized
the Programs,4against any claim by or on behalf of the registrant as a
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4 rincluding the owners
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K transported
3 in3 the Programs,
3 participation
3 3 and/or being
3
b
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result of registrant’s
or from the same which transportation I hereby authorize
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Eastern iPennsylvania Youth Soccer
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l Butler Pike,
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4070
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l 100 I Plymouth Meeting, PA 19462 I 610.238.9966 I www.epysa.org
2
i Rev. 4/15
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s SOCCER FEDERATION i(USSF) AND FEDERATION l
RG-6(P)
AFFILIATED
WITH UNITED STATES
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