“ New Registration $80.00 “ New or Return $60.00

(Includes Uniform) (Does NOT include uniform)

“ Returning Player $45.00

“ Shirt $21.00

“ Shorts $8.00

“ Socks $6.00

“ Late Registration Fee $10.00

Total $________ Total $ ________

Players Name: _______________________________________ Phone Number_______________________

Date of Birth: _____/_____/_____ Sex: ________ School ______________________________________

Address: _______________________________________________________________________________

City: ___________________ State: ________________ Zip:_______________

Played Last Spring?:______ Played Last Fall? _______ If yes, Coach’s Name: _____________________________

Allergies/Health Problems: ________________________________________________________________________

Parent/Guardian Name(s)_______________________________________Parents Cell Phone Number:_________________________

Email Address: _________________________________________________________________________________

Emergency Contact: ______________________ Phone Number: ____________________ Relationship to Player________________

Special Request:_____________________________________________________________________________________________

(Circle One)

Jersey: YS YM YL AS AM AL AXL

Shorts: YS YM YL AS AM AL AXL Socks: S M L

ð Coach ð Asst. Coach ð Referee ð Refreshments ð Field Maintenance ð Field Set Up ð Line Painting

ð Uniform Distribution ð Refreshment Committee ð Team Set up ð Other: _____________________________

We, the undersigned parent/guardian of a West Mifflin Soccer Club Player, do hereby agree that he/she may participate fully in the practice and game of soccer. We do further agree or and on behalf of our child, and for ourselves individually and severally, that we will assume all risks attendant to traveling and playing soccer and related activities and that we will not hold West Mifflin Soccer Club (WMSC), their coaches, member, or board of directors liable for any claims involved in Soccer. I hereby release WMSC form any liability for their acts or omissions. I have receive a copy and/or read and agree to the terms of the WMSC good sportsmanship agreement.

Parent/guardian Signature: ________________________________________

Travel Registrants must also sign below:

I request that my child be registered on ____________________ team for the fall and the following spring season. If tryouts are required, I understand my child will be placed, or not placed on team based on the results of the try outs. I further understand that no transfer to another team will be allowed unless both coaches and the WMSC agree, as required by PAWest rules. I agree that if my child does not play in the Spring, he/she may be dropped from the roster so that another child may be added. My child is not a member of another soccer club, nor have they registered with another soccer club for this same season.

Parent/guardian Signature: ________________________________________

DO NOT WRITE BELOW - WMSC Use Only

WMSC Initials: _________ Birth Cert Checked: _______ Check No. ___________ Cash: _____________ Date: ____________ Number of 50/50tickets _______________