This form must be filled out by a parent or legal guardian.

Fill this form out completely.  There is only one required field on this form.  You must enter an email address for Your Email Address.  It's ok to leave some fields blank if you don't have the information, but it could hold up the processing of the registration.  One form must be completed for each player. 

A verification form will be emailed to you at your email address.  Please sign the form and mail it with your check and a copy of the player's birth certificate to complete the registration process.

Player Information - Make sure you select Fall 2008 or Spring 2009 season below.

   Please enter the player's uniform size:   I am registering for Fall 2008 OR SPRING 2009
Last Name: First Name: Middle Initial: Suffix Nickname
Address: City: State: Zip Code Area Code / Phone
()-
Emergency Contact: Emergency Phone:  Physician Name: Physician Phone: 
()- ()-
Gender Birth Date:
(mm/dd/yyyy)		 Age: School Name Your Email Address:
(Required)
Boy
Girl
Medical Insurance Carrier: Names of Siblings
on The Same Team		 Experience
(years)		 Height Weight

Mailings (check all that apply)

Hearing Impaired: VIP: AYSO Mailings: Other Mailings:

Parent Information
Father / Guardian: 

Last Name: First Name: Middle Initial: Suffix Nickname
Business / Employer: Email Home Phone Work Phone
()- ()-

AYSO is an all volunteer organization, I want to apply for:

Coach Assist Referee Other

Mother  / Guardian: 

Last Name: First Name: Middle Initial: Suffix Nickname
Business / Employer: Email Home Phone Work Phone
()- ()-
AYSO is an all volunteer organization, I want to apply for:
Coach Assist Referee Other

Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition? Yes No .   If yes, please state conditions or problems here:

Players of the same gender living in the same household may be placed on the same team if their birthdates coincide with those of the same age-division. Please list the name of any such player you wish to be assigned to the same team as the player you are now registering: