LAST NAME_ FIRST NAME ___

ADDRESS _______________________________________ CITY __________________

PHONE NUMBER __________________ ZIP CODE _____________

DATE OF BIRTH ___________________ CIRCLE - MALE FEMALE

PARENTS INFORMATION

FATHER’S NAME MOTHER’S NAME ___

CELL NUMBER___________________ CELL NUMBER _______________________

E-MAIL __________________________ E-MAIL ______________________________

VOLUNTEERS

The United Soccer Club is a volunteer organization, in order to run efficiently we need all the volunteers we can get. Please check an area you would be interested in:

Coach _________ Concessions __________ Q-Store ___________ Team Mom ______

AGE GROUPS

(Circle one)

___SMIDGETS 1:30 OR 3:30 (8-1-98 THRU 7-31-00) $85.00 includes uniform shirt

___UNDER 6 (8-1-98 THRU 7-31-99) $105.00 includes uniform shirt

___UNDER 8 (8-1-96 THRU 7-31-98) $115.00

___UNDER 10 (8-1-94 THRU 7-31-96) $125.00

___UNDER 12 (8-1-92 THRU 7-31-94) $125.00

___UNDER 14 (8-1-90 THRU 7-31-92) $125.00

___UNDER 16 (8-1-88 THRU 7-31-90) $125.00

___UNDER 18 (8-1-85 THRU 7-31-88) $125.00

UNIFORM SIZES

Uniforms are red and white shirts, black pants, red and white socks.

ONLY order a uniform if you played before Fall 2003.

Uniforms cost $35.00

CIRCLE ONE: YS YM YL YXL AS AM AL AXL

MEDICAL INFORMATION

Any physical or medical condition we should know about? YES NO

If YES, what are they? __________________________________________________

REQUEST

_________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

PLAYERS INFORMATION

LAST NAME_______________________ FIRST NAME _________________________