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Eastern Pennsylvania Youth Soccer Association Participant Registration Form
PLAYER COACH ADMINISTRATOR


CHECK ONE: CHECK ONE: CHECK ONE: League: Blue Mountain

Travel
Intramural
New EPYSA Registrant
Returning Registrant
Player
Coach
Administrator
Club Name: Bath - East Allen

Age Division U.-_________

S.S.#____________Last Name:________________________First Name:_______________________

Address:____________________________________________Telephone:______________________

City:____________________________________________________State:_______Zip:__________

Birth Date:___________Sex:M F  Parent/Guardian:__________________________________

Coaching License:__________________Administrator's Title:_______________________________

Administrator's Committee:___________________________________________

Release Statement

NOTE: The Statement should be signed by parent/guardian for minor player; an adult player for himself; coach for him self;and administrator for himself.

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

Parent/Guardian or Adult Signature:___________________________________Date:____________


Eastern Pennsylvania Youth Soccer Association
Two Village Road,#3 - Horsham, PA 19044 - (215)657-7727
Affiliated with the united States Soccer Federation (USSF) and Federation International de Football Association (FIFA)


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