• PLAYER'S NAME:

  Name
  Father's Name	Mother's Name
  Date of Birth
  Birth Certificate Number	(ATTACH COPY)
  Sex	Male Female

   

• IS THE PLAYER:                                                                YES        NO

                    - a dedicated goalie?                                                                        

                    - interested in rep play?                                                                     

                    - involved in another sport? i.e. Hockey                                           

• Please provide the following contact information:

  Street Address
  Address (cont.)
  City
  State/Province
  Zip/Postal Code	Country
  Work Phone	Home Phone
  FAX	E-mail

• Preference:

• Please provide soccer experience:

• Please provide special needs or medication:

• VOLUNTEERS ARE A VITAL PART OF OUR SOCCER CLUB. PLEASE CHECK AT LEAST ONE OF THE FOLLOWING BOXES:

Family discount: Full price for 2 eldest children. No charge for each additional child.

A $20 discount applied to all registrations received before June 30, 2006.

***Registration fees and uniform deposit must be paid in full for registration to be processed.***

_____________________________________________________________________________________________________

          Mail In Registration with payment to:

        A. V. Y. S. A.

        P. O. Box 384, port alberni, B.C., v9y 7m8

If mailing registration, please pay by cheque or money order and submit a $50.00 refundable uniform deposit, post-dated April 30, 2007.