Hamburg Area Soccer Association

Eastern Pennsylvania Soccer Association Participant Registration Form
Player Coach Administrator
Check One: Travel (All HASA Teams) Intramural	Check One: New EPYSA Registrant Returning Registrant	Check One: Player Coach Administrator	League: RBJSL Club Name: HASA Age Division:
Social Security#:       Last Name:    First Name:
Address:            Telephone:
City:           State:        Zip:
Birth Date / /     Sex: M F                   Parent/Guardian Name:
Coaching License:          Administrator's Title:
Administrator's Committee:         Email Address:
All Returning Registrants - Please provide an up-to-Date 1"x 3/4" Photo for official players pass All New Registrants - Please provide a copy of birth certificate and 1" x 3/4" Photo for official players pass Release Statement NOTE: The Statement should be signed by parent/guardian for minor player; an adult player for himself; coach for himself; 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, it's affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the EPYSA accepted the registrant for it's soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the EPYSA, it's 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, Suite #3 Horsham, PA 19044, (215)657-7727 Affiliated with United States Soccer Federation (USSF) and Federation Internationale de Football Association (FIFA) Hamburg Area Soccer Assoc. MEDICAL RELEASE FORM
Health Insurance Info: Policy Name:
Health Insurance Info: Policy#:             ID#:
Family Physician:                Telephone:
Emergency Contact Person: Telephone:
Medical conditions that the coach should be aware of (such as allergies, etc.):
In the event that I am unable to give consent at the time of a medical emergency, I give permission for the registrant listed above to receive medical treatment.
Parent/Guardian or Adult Signature: ________________________________________ Date / /

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