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East Providence Youth Soccer Association

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Fall 2018 Recreational Pre Registration

If you are a human and are seeing this field, please leave it blank.

Fields marked with an * are required

Player First Name *

Players Last Name *

Gender *

• Male
• Female

Must be 3 years old by September 1st of the current year

My Child's Soccer Experience * Never Has Played Played Recreational Played Competitive

Date of Birth (xx/xx/xxxx) *

Address 1 *

City *

State * Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Zip / Post Code *

Parent/Guardian #1 Full Name *

Parent/Guardian #1 Phone Number *

Parent/Guardian #1 Email Address *

We encourage parents to volunteer. Please indicate how you would like to help: Coach Manager Sponsor

What is Six + 4 *