PA West Soccer ODP

PA West Youth Soccer Olympic Development Program
Secure ODP Enrollment Form
2008-2009

NOTE! All ODP information will be sent by email to the Email Address provided below.
All ODP information will be sent by email.
Please be sure to set your email filter to accept email from domain @PA Westyouthsoccer.org.
Only persons for whom the PA West Youth Soccer has this current ODP Enrollment Form
and required documents on file will receive ODP information.
Note: If paying by credit card, your credit card will show a charge from "Hammerhead Communications"

Required fields are marked with an asterisk*.

Player Information

Player's Name*

First Last

Birthdate* & Gender*

mm dd yyyy Boy Girl

Street Address*

City, State & Zip*

Home Phone*

( ) -

Contact Email Address*

Confirm Email Address*

Position*

Forward Midfielder Defender Goalkeeper

Are you a US Citizen?*

Yes No

High School or College (if applicable)

High School Graduation Year

High School GPA

Club*

Adult t-Shirt Size*

Small Medium Large X-Large

Parent/Legal Guardian Information*

Mother's/Legal Guardian's Name

Mother's/Legal Guardian's Home Phone

( ) -

Mother's/Legal Guardian's Work Phone

( ) -

Mother's/Legal Guardian's Mobile Phone

( ) -

Father's Name

Father's Home Phone

( ) -

Father's Work Phone

( ) -

Father's Mobile Phone

( ) -

Alternate Email Address

Confirm Alternate Email Address

Medical/Insurance Information

Family Physician

Family Physician Phone

( ) -

Family Dentist

Family Dentist Phone

( ) -

Insurance Provider

Insurance Provide ID #

Payment Information - $25.00

Method of Payment:

Check Credit Card (Mastercard or Visa)
Note: If paying by credit card, your credit card will show a charge from "Hammerhead Communications"

For Credit Card

Credit Card #:

Credit Card Exp. Date:

Name on Card:

Cardholder's Street Address:

Cardholder's Zip Code:

Promotional Release*

I undestand that occasionally photos and/or video will be taken of the players to be used in promotionalmaterials for ODP. I agree to allow my child's image to be used for non-profit promotional purposes.

This program is duly authorized through the United States Soccer Federation as being part of the Olympic Development Program (ODP). ODP Teams are based on the January 1st Birth Years in compliance with U.S. Youth Soccer & FIFA Circular # 504.

By checking the box at left, We hereby acknowledge and certify via electronic submission/signature that we are the parents/legal guardians for the player/participant listed herein. Further, We (player and parents/legal guardians) further agree to abide by the rules, regulations, policies and decisions of the PA West Youth Soccer and to participate in the PA West Olympic Development Program as determined by the PA West Youth Soccer. We also certify that the information provided herein is complete and accurate. We grant permission to the PA West Youth Soccer to use any and all photographs, videography and information provided herein and throughout the ODP process for the purpose of conducting business for the PA West Youth Soccer. We agree that the PA West ODP Enrollment and all ODP Program fees are non-refundable. We understand that the player will not be permitted to participate in the ODP process until PA West Youth Soccer is in receipt of the player’s PA West Youth Soccer ODP Enrollment Form, PA West Youth Soccer Emergency Medical Release and Liability Waiver and Birth Certificate or legal proof of age. We acknowledge and fully understand that the player is engaging in activities that involve risk of injury, including permanent disability or death, and severe social and economic losses. We hereby give our consent for emergency medical care and accept personal responsibility for the damages. We also agree to save and hold harmless, to indemnify and not to sue the PA West Youth Soccer, its directors, officers, employees, coaches, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event (hereinafter collectively referred to as releasees) from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, caused, or claimed to be caused, and any injury or accident resulting from participation or alleged to be caused in whole or in part by the negligence of the releasees.

I/we (above indicated) hereby acknowledge that I/we have reviewed this form and caused it to be electronically executed with the intent to be bound to the terms contained herein*.

Please click ONLY ONCE on the Submit button above.
Sometimes, it takes a few seconds for the form to be processed. Thank you.

An Important Note from the PA West Soccer Office if paying by credit card:
You will also receive a credit card receipt from our credit card processing vendor Hammerhead Communications from the email address: receipts@Hammerhead.net.

Note: Your credit card statement will show a charge from "Hammerhead Communications"