West Virginia Soccer Association-Membership Form
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1OFFICIAL USE ONLY
West Virginia Soccer
Registration Fees:
$____________________
Player Fee
$____________________
Association
Coaches Fee
$____________________
Other
$____________________
TOTAL PAID
$____________________
Cash:________ Check #________Credit Card_________
MEMBERSHIP FORM
Pictutre:
Yes ______
No _______
Birth Certificate Verified Yes ______
No _______
First Name ____________________________________Last Name______________________________________
Address _____________________________________________________________________________________
City _____________________________________________State ___________________Zip________________
Home Phone _________________________ Birth Date _____________________
Male ____ Female ______
US Citizen ____ Yes ____ No
Parent Email Address _________________________________________
Are you or do you plan to register on another team during the current Seasonal year (September 1 thru August 31)
If yes, please complete:
League Name______________________ State _______Team Name ____________________Age Group_______
Please check Type of Team:
Recreational Team _________
Competitive Team ___________
Father’s Name __________________________________________ Occupation _____________________ Cell #____________________
Mother’s Name__________________________________________ Occupation_____________________ Cell # ____________________
IMPORTANT
I, parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the WVSA; its affiliated organizations
and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the WVSA accepting the
registrant for its soccer programs and activities (the “Programs”), I hereby release, discharge and/or otherwise indemnify the WVSA, 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.
Print Name: __________________________________________________________________________________Parent/Legal Guardian
Signature:_____________________________________________________________________________Date:_____________________
[ ] I do not authorize West Virginia Soccer Association to include my child(ren)’s information in any lists which are sold to vendors. My
child(ren)’s contact information is to be used for WVSA-related business only.
Uniform Sizes
Other Children from Same Family registered with this league
PARENTAL SUPPORT
___Youth
____Adult
Name:_____________________________________ Age:_______
We ask for active participation of
Shirt
XS S M L XL
Name:_____________________________________ Age:_______
all parents in our program. Circle
Shorts XS S M L XL
area(s) in which you would be
Socks XS S M L XL
Name:_____________________________________ Age:_______
willing to help.
Coach
Committee
List any Medical problem or prohibition the player has: ____________________________________
Asst Coach
Referee
Team Manager Fund Raising
Team Parent
Special Projects
Person to notify in emergency:___________________________________Telephone:____________
Concessions
Donation
Doctor to notify in emergency:___________________________________Telephone:____________
Board Member Newsletter
Number of prior seasons played:____________________________ League___________________
Field Preparation Clerical
Last Season Played____________
Rec ____ Travel____ Middle School ____High School _____
Other ______________________
Height: _________ Weight _________ School:_______________________________Grade______
WVSA is affiliated with the United States Soccer Federation , United States Youth Soccer, United States Amateur Soccer Association
Revised 2011
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