PART 1     PLAYER INFORMATION

First Name                  Last Name

Gender -- Male Female                                                  Birth Date Mo. Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Day 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Current school                Shirt size -- YS YM YL AS AM AL AXL

Recreational or travel division -- Recreational Travel         If recreational, which practice group? -- Hermitage Sharon Sharpsville

Player ID# (player ID is the last 6 digits of player's social security #)

Allergies or special medical concerns?

PART 2     GUARDIAN'S INFORMATION

First Name                            Home Phone

Last Name                              Cell Phone 

Address 1                                       Email 

Address 2        Emergency Contact Name 

City                              Emergency Phone 

State          -- AL AK AZ AR CA CO CT DE DC FL GA GU HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA PR RI SC SD TN TX UT VT VA WA WV WI WY AB BC MB NB NF NT NS NU ON PE QC SK YT                                                    Parent will volunteer as a

Zip                                   coach   coach's helper  clerical       field maintenance 

PART 3A     SHENANGO VALLEY SOCCER RECREATIONAL PROGRAM

Fees:  First player per household $35; Second player per household $30; third and subsequent player $25

Player Fee       -- $35 $30 $25                     I do not need a new jersey for this player

Amount owed  -- $35 $30 $25 $20

PART 3B     SHENANGO VALLEY UNITED TRAVEL PROGRAM

$72 per player (registration and socks); Standard travel team jersey $20

Register this player for the Shenango Valley United travel team division: Fee $72  -- $65

I need a jersey for this player.  Fee: $20                                                              -- $20

I have a travel team jersey for this player. The jersey number is                           

The  total fees for this travel team player are:                                                        -- $65 $85

PART 4     PAYMENT INFORMATION

Type  -- select -- Money order Check           Check #          Total amount paid -- $85 $65 $35 $30 $25 $20  

SEND YOUR PAYMENT TO

Registrar

4928 Tamarack Dr

Sharpsville, PA  16150

WRITE THE PLAYERS NAME ON THE BOTTOM LEFT CORNER OF THE CHECK.  ALL PAYMENTS MUST BE BY CHECK OR MONEY ORDER. PLEASE DO NOT SEND CASH PAYMENTS

PART 5     Guardian Consent

To sign this document electronically, fill in the player's name, their player  ID number and your name in the boxes below.  By filling in this information you are indicating that you are the player's legal guardian and that you consent to the terms listed below

GUARDIAN'S CONSENT:

I understand that soccer is a contact sport that can result in serious or fatal injuries.  I attest that I am a legal guardian of (player's full name)  and give permission for her/him to participate in practices, competitions, and other activities sanctioned by SAYSA {the club}, or its Shenango Valley United or Shenango Valley Soccer divisions. I agree to hold the coaches, the club, its members, directors and property owners harmless for any injury, should they occur.

To electronically sign this consent form:

Enter Player ID # here

Enter your first and last name here

Click Submit to submit this application to the club, then reset to clear the form