LAUSA Javier Rodriguez, Director

Player 1/Captain (Please print) Check if playing in Goalie Shootout ___ Name _____________________________ Address ___________________________ City ___________ State ___ Zip ______ Age ___ Date of Birth ___/___/___ Daytime Phone ____________________ E-mail ___________________________ Check T-shirt Size: Child: M __ L __ XL __ Adult: M __ L __ XL __ XXl __ _________________________________ Signature of parent or guardian if player is under 18	Player 2 (Please print) Check if playing in Goalie Shootout ___ Name _____________________________ Address ___________________________ City __________ State ___ Zip _______ Age ___ Date of Birth ___/___/___ Daytime Phone ___________________ E-mail __________________________ Check T-shirt Size: Child: M __ L __ XL __ Adult: M __ L __ XL __ XXL __ ________________________________ Signature of parent or guardian if player is under 18	Entry Fee: - All teams Entry fee of $150.00 per 5 players team must accompany your registration form before July 21st ($175.00 per 5 players after July 21st) - Add $5 per player and check Goalie Shootout in that player's registration section. - Please one check per team. - We reserve the right to move a team up an age group if necessary. - Check the website for directions and game times. Office Only: Received by ______ Amount Paid ______ Date Received __ / __ /__ Check No. ___ Reply ____________ Balance $ ____ Entered ________________
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Player 3 (Please print) Check if playing in Goalie Shootout ___ Name _____________________________ Address ___________________________ City ___________ State ___ Zip ______ Age ___ Date of Birth ___/___/___ Daytime Phone ____________________ E-mail ___________________________ Check T-shirt Size: Child: M __ L __ XL __ Adult: M __ L __ XL __ XXl __ _________________________________ Signature of parent or guardian if player is under 18	Player 4 (Please print) Check if playing in Goalie Shootout ___ Name _____________________________ Address ___________________________ City ___________ State ___ Zip ______ Age ___ Date of Birth ___/___/___ Daytime Phone ____________________ E-mail ___________________________ Check T-shirt Size: Child: M __ L __ XL __ Adult: M __ L __ XL __ XXl __ _________________________________ Signature of parent or guardian if player is under 18	Contact person: Mr. Javier Rodriguez (570) 233-0238 Dr. Jerry McDonald (570) 332-0723 Wyoming Valley Soccer Club P.O. Box 244 Dallas, PA 18612
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Player 5 (Please print) Check if playing in Goalie Shootout ___ Name _____________________________ Address ___________________________ City ___________ State ___ Zip ______ Age ___ Date of Birth ___/___/___ Daytime Phone ____________________ E-mail ___________________________ Check T-shirt Size: Child: M __ L __ XL __ Adult: M __ L __ XL __ XXl __ _________________________________ Signature of parent or guardian if player is under 18

Application - Saturday/Sunday, August 5-6, 2006	Playing Saturday: Coed U-7/U-8___ U-9___ U-10 ___ U-11___ U-12__
_________________________________________ Team Name	Playing Sunday: U-13 ___ U-14 ___ U-15 ___-16 ___ U-17 ___ U-19 ___ Coed High School ___
_________________________________________ Contact Person	Women's College __ Men's College __ Coed Open __ Women Open __ Men Open __ Over 40 Men__
_________________________________________ Address	**********************************************************************
City _____________ State ______ Zip ________	Goalie Shootout!
____________________________ Phone ____________________________ E-mail	We challenge you to our Goalie Shootout - the fast pace one-on-one soccer shootout. Not just for goalies - its for all players who can score and stop shots. Play begin after 2:00PM on Saturday. 5 shots for $5.00 --- Just like penalty kicks.
Team Gender Male ______ Female ______ Co-ed ________ Team Attitude: Recreational ________ Competitive _______	***********************************************************************