| 2004 Application/Questionnaire | |
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Oldest Birth Year:______ Age Group: Under-______ (2004/2005 season) Team:___________________________________ Club:___________________________________ Affiliation (Select only one) USYSA (State Association:__________________) US Club Soccer Super Y League FIFA Affiliation:_________________________ and Country_________________________ Team Colors:_____________________ Team Home City:_________________________________________ Team Contact Person:_______________________ Address:_______________________________________ City________________________ State______ Zip____________ Phone: (_____) ______-___________ Cell: (_____) ______-____________ Fax: (______) _______-__________E-Mail: __________________ Named Coach for the Program:_______________________________________ The Selection Committee accepts teams based on evaluation of their record. To gain entry into the tournament and to assist with proper seeding, please complete the questionnaire. YOUR APPLICATION IN THIS YEAR’S TOURNAMENT CANNOT BE CONSIDERED WITHOUT COMPLETING THIS FORM. Results will be verified. 2003-2004 Record Overall: Wins:______ Losses:______ Ties:______ League:________________________ Wins:______ Losses:______ Ties:_____ Finish:____________________ Snickers State Cup Results: 2004 Nationals: Wins: _____ Losses:_____ Ties:_____ Finish:________ Comments:________________ 2004 State Cup: Wins: _____ Losses:_____ Ties:_____ Finish:_______ _________________________ 2004 Regionals: Wins: _____ Losses:_____ Ties:_____ Finish:_______ _________________________ 2003 Nationals: Wins: _____ Losses:_____ Ties:_____ Finish:_______ _________________________ 2003 State Cup: Wins: _____ Losses:_____ Ties:_____ Finish:_______ _________________________ 2003 Regionals: Wins: _____ Losses:_____ Ties:_____ Finish:_______ _________________________ Other State Cup Results: (e.g. Open Cup): 2004 Tournament _______________________________: Wins: _____ Losses:_____ Ties:_____ 2003 Tournament _______________________________: Wins: _____ Losses:_____ Ties:_____ Other Major Tournaments: Tournament Year Flight* Wins Losses Ties Finish 1. ______________________________ ____ _____ _____ ______ ____ _____ 2. ______________________________ ____ _____ _____ ______ ____ _____ 3. ______________________________ ____ _____ _____ ______ ____ _____ 4. ______________________________ ____ _____ _____ ______ ____ _____ 5. ______________________________ ____ _____ _____ ______ ____ _____ * Flight means level of play such as top, Premier, Gold, Silver, etc. Games Against State, Regional, or National Champions: Your Team vs. __________________________ Score:______ Your Team vs. __________________________ Score:______ Your Team vs. __________________________ Score:______ Your Team vs. __________________________ Score:______ Information on your record must be completed on this page in order for your application to be accepted. Additional pages may be attached to further explain your record. Official Use Only: Postmark Date: Date Received Paid: Approved: Denied: Notice Sent: Refund Sent: Pleasanton Rage College Showcase 2004 Team: __________________________________ Age Group: Under________ Application Player Roster: The following application player roster is required to enable the Tournament Committee to validate the age group for your team through validation of birth date for players on your roster. Complete the roster using information currently available for your team. During the player credential at check in, the final player roster will be required. Final player roster will be established at the Mandatory Registration and will be based upon your presented documentation, including Travel Papers when applicable. Name Birth Date Name Birth Date 1.___________________________ __________ 10. ______________________ ___________ 2.___________________________ __________ 11. ______________________ ___________ 3.___________________________ __________ 12. ______________________ ___________ 4.___________________________ __________ 13. ______________________ ___________ 5.___________________________ __________ 14. ______________________ ___________ 6.___________________________ __________ 15. ______________________ ___________ 7.___________________________ __________ 16. ______________________ ___________ 8.___________________________ __________ 17. ______________________ ___________ 9.___________________________ __________ 18. ______________________ ___________ Documents that will be needed at registration (Check In) will include the following: team roster; laminated player identification cards showing picture, date of birth, team identification number, and signed by a league or state official; medical release forms. In addition: • USYSA teams traveling from outside Nevada will be required to present Travel Papers, including the Application to Travel form and Travel Roster. • Us Club Soccer and Super Y League teams will be required to present their approved team roster and will be required to certify at registration that all players are in good standing and are not in a suspended status from any USSF affiliated organizations. Waiver of Liability: If accepted to participate in the Rage College Showcase tournament, we agree to release, indemnify, and hold harmless, tournament officials, referees, sponsors, or any other representatives from any action brought about through claims, law suits, or any type of judgment that may rise out of any injury, physical or monetary, to the above named participants on this team. Limited refunds will be given for cancellation due to acts of God. We also agree participants may be photographed during the event and those photographs may be used for reasonable promotional purposes. This signature also certifies we have read and understand the application rules and we agree to abide by them. Team Official: _______________________ _________________________ Date: _________________ (print) (sign) Questions: Please contact Rage College Showcase office (925) 209-9983 or by e-mail at RageShowcase@pleasantonrage.org Mail your completed application with check or money order payable to: Pleasanton Rage College Showcase P.O. Box 885--Pleasanton, CA 94566 |
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