Jarosi-Willis Memorial

ADMINISTRATOR ENTRY FORM

Registration Fee Rcvd: Yes No	Check No.
Bond Fee Rcvd: Yes No N/A	Check No.

TEAM INFORMATION

Team Name:

Gender:
Boys Girls

Age Group: verify division by age

Club Name:

Birthdate of Oldest Player: (format: 04/04/1992)
/ /

Team Affiliation: (choose one)
US Youth Soccer US Club Soccer N/A

If checked US Youth Soccer, your State Association:

Coach's Name:

Coach's Phone #s (with area code):

PRIMARY CONTACT PERSON

This person will serve as the primary contact for all Jarosi-Willis Memorial Cup communications.
Please be sure to enter a valid working email address, as confirmation of your
registration will be be delivered to the Primary Contact's Email address indicated below.

Team Contact:

Role with Team:

Team Contact Email Address:

Confirm Email Address:

Team Contact Street Address:

Team Contact City, State, Zip:

City	State	Zip

Team Contact Home Phone # (with area code):

Team Contact Work Phone # (with area code):

TEAM PERFORMANCE HISTORY

Although not required, the information requested below helps the committee in the team selection process.

# of years team has played in the Jarosi-Willis Cup:

2003 Record at the Jarosi-Willis Memorial:

Won:

Lost:

Tied:

Fall 2003 League Name:

Division:

Record:

Place:

Most Recent State Cup
or State Championships:

Division:
N/A

Record:

Place:

Spring 2004 League Name:

Division:

Record:

Place:

Tournament Name

Year

Div.

Record

Place

Additional Comments: List any information which will assist the selection committee in a proper evaluation.

SUBMISSION & PAYMENT INFORMATION

TERMS & AGREEMENTS

	I understand that inclement weather, acts of God or other uncontrollable circumstances are always a possibility and such occurrences may result in the abbreviation or cancellation of tournament games and that in the event this occurs, no refunds (partial or full) will be given.
	I CERTIFY THIS APPLICATION IS ACCURATE AND COMPLETE.

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