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Web Space
Kindly Provided By Red River Communications
Lake Havasu 928/505-2999
Kingman 928/718-1817
AYSA
Registration
Phone # 453-8099 2156 McCulloch Blvd. Suite 9, Lake Havasu City, AZ
Lake Havasu Soccer League A.Y.S.A. Membership Form
Must have copy of Birth Certificate and Registration Fee, Incomplete applications will not be accepted!
(One child per application please)
Last Name ________________________ First Name _________________________
Address _____________________________________________________________
D.O.B. ______________________ Age ____________________ Gender M / F
Parent / Guardian Name ________________________________________________
Day Time Phone # ____________________ Evening Phone # ___________________
Experience ______________ Grade ________ School of Residence ______________
Parental Support Coach:____ Assist:____ Sponsor:____ Board:____ Team Mom:____
Consent for Medical:
As the parent / guardian of the above player I give consent for the medical treatment to preserve the well being of my dependent. I also consent to release all claims towards the above organization Director or owner of the facilities against any claims on behalf of the registered player.
Parent / Guardian Signiture ____________________ Date _____________________
