INTRAMURAL REGISTRATION FORM
Please complete this registration form to sumbit your information. You will then be taken to a payment options page.
   Step 1 Registration Information -- Step 2 Payment Options
PARENT / GUARDIAN INFORMATION
 PARENT/GUARDIAN INFO
PARENT 1
 LAST NAME:
 FIRST NAME:
 ADDRESS:
 CITY:
 STATE:
 ZIP:
 PHONE NUMBER:
 E-MAIL ADDRESS:
 Interested in Coaching?
 Shirt Size:
 PARENT/GUARDIAN INFO
PARENT 2
 LAST NAME:
 FIRST NAME:
 ADDRESS:
 CITY:
 STATE:
 ZIP:
 PHONE NUMBER:
 E-MAIL ADDRESS:
 Interested in Coaching?
 Shirt Size:
***COST $50 PER CHILD***
PLAYER INFORMATION
 PLAYER INFO
FIRST PLAYER
 NAME:
 AGE (as of 6/1/2010):
 SEX:
 SHIRT SIZE :
 Interested in Instructional Games?
 Medical Concerns:
 PLAYER INFO
SECOND PLAYER
 NAME:
 AGE (as of 6/1/2010):
 SEX:
 SHIRT SIZE :
 Interested in Instructional Games?
 Medical Concerns:

 PLAYER INFO
THIRD PLAYER
 NAME:
 AGE (as of 6/1/2010):
 SEX:
 SHIRT SIZE :
 Interested in Instructional Games?
 Medical Concerns:
 PLAYER INFO
FOURTH PLAYER
 NAME:
 AGE (as of 6/1/2010):
 SEX:
 SHIRT SIZE :
 Interested in Instructional Games?
 Medical Concerns:

****COST $50 PER CHILD***
 RELEASE STATMENT & SIGNATURE APPROVAL
 RELEASE STATEMENT:
I, the parent/guardian of the registrant, a minor, or adult of legal age, agree that the registrant and I 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 association personnel, including the owners of the fields and facilities utilized for the program, against any claim by or on behalf of the registrant as a result of the registrants participation in the program,and/or being transported to or from the same, which transportation I do authorize. ***By placing my name in the box below I am accepting this release statement.
 SIGN HERE :
You must place your name in this box before going on to the next block.
 Please select your desired method of payment:
Credit/Debit Card       Check

* If you are paying by check please print this completed form prior to selecting the submit button.
   
 
     

 

PYSA © 2010