Kentucky Youth Soccer Association

Kentucky Youth Soccer Association
Complete the form below, then press the "Submit" button.
Kentucky Youth Soccer Association Accepts Check or Mastercard/Visa Payment.
Required Fields are Marked with a "*" Use Proper Punctuation, Please Turn Off All Caps.

Select the Camp Session You Would Like to Attend*:

Personal Information:

Please Note: The Email address below will be used as the main means for all future camp communications.
Proper Punctuation is Required, i.e.: "John Smith", NOT "john smith" or "JOHN SMITH"

Player First Name*	Player Last Name*
Player Street Address*	Player City, State, Zip*
Parent Email Address*	Player Date of Birth* Month Day Year
Player Age*	Level of Play
Home Phone* ( ) - -	Work Phone Number ( ) - -
Name of Emergency Contact*	Emergency Contact Phone Number * ( ) - -
KYSA Club Affiliation	T-Shirt Size* Youth Medium Youth Large Adult Small Adult Medium Adult Large

Medical Release

I/we hereby agree that the local organizing soccer group and the KYSA Clinic shall not be liable for any injury or loss which my child(ren) may sustain while participating in this soccer clinic, and I agree to indemnify and to hold harmless the organizing soccer group and/or the KYSA Clinic from any claim whatsoever.

Agree to Terms Above: Yes No
Known Medical Problems/Allergies:

Payment Information

Payment Method: * Check Credit Card

If you have a sibling attending a camp, you are entitled to a $10 discount. To receive the discount, please enter a Discount Code of "sibling" below to receive a $10 discount. Discount is applied immediatley.
Discount Code: $
Please List Sibling Attending KYSA Summer Camp * :

Please note that this sibling will need to fill out a separate registration form.
Entering the sibling name above DOES NOT register the sibling for this camp session.
KYSA will audit all sibling discounts to verify there is a sibling attending a KYSA summer camp.

Your Camp Fee: $

Name as it Appears on Credit Card	Credit Card Type MasterCard Visa
Credit Card Number	Credit Card Expiration Date /
Credit Card Holder's Street Address:	Credit Card Holder's Zip Code:

Agreement for Electronic Submission

has my permission to attend The Kentucky Youth Soccer Association Soccer Camp. Should the need for medical treatment arise, the director of the camp or athletic trainer has/have my permission to seek care at an emergency center at my expense.

Please click ONLY ONCE on the Submit button above.
Your Credit Card will be charged each time you press submit.
Sometimes, it takes a few seconds for the form to be processed. Thank you.
Please email adrianparrish@kysoccer.net if you have any problems.