USYSA Membership Form

United States Youth Soccer Association Membership Form

Player Information
New Player or Existing Player?*
- New Player
- Existing Player
For New Players: Please attach a scanned copy of your player's birth certificate (required). Or, you can send a copy to PO Box 604 Montrose, CO 81402 or give a copy to a coach.
Last Name*
First Name*
Middle Initial*
Address*
Street AddressAddress Line 2CityStateZip Code
Telephone Number*
Birthdate*
Male/Female*
- Female
- Male
Parent/Guardian Information
Father's Name*
Father's Occupation
Father's Bus. Phone*
Mother's Name*
Mother's Occupation
Mother's Bus. Phone*
List any medical problem or prohibition player has
Person to Notify in Emergency*
Emergency Contact Phone Number*
Doctor to Notify in Emergency*
Doctor's Phone Number
Number Prior Seasons Played*
Please enter a value between 0 and 35.
Date of Last Season
Last Team
Last League
School
Public School District
Grade
Email 1*
Email 2
Release
I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the USYSA, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with soccer and in consideration for the USYSA accepting the registrant for its soccer programs and activities (the "Programs"), I hereby release, discharge and/or otherwise indemnify the USYSA, its affiliated organizations and sponsors, their employees and associated peronnel, 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 being transported to or from the same, which transportation I hereby authorize.*
By checking this box, I acknowledge my digital signature.*
- Signature of Parent/Guardian
Consent for Medical Treatment (Minor)
As the parent or legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb, or well being of my dependent. Please type your name below.*
By checking this box, I consent to medical treatment for my dependent.*
- Signature of Parent/Guardian
Address*
Street AddressAddress Line 2CityStateZip Code
Phone*
Business Phone*
Parental Support
Parental Support: We ask for active participation of all parents in our program. Please check the area(s) in which you would be willing to help.
- Coach
- Asst Coach
- Team Manager
- Team Parent
- Special Projects
- Field Preparation
- Board Member
- Publicity
- Committee
- Referee
- Fundraising
- Clerical
- Reporter
- Newsletter
- Concessions
- Donor
Please type the words below.

United States Youth Soccer Association

Youth Division of the United States Soccer Federation (USSF) Affiliated with the Federation Internationale de Football Association (FIFA)

USYSA Membership Form

Player Information

Parent/Guardian Information

Release

Consent for Medical Treatment (Minor)

Parental Support

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