Div.: U-10 U-12   U-14   U-16   U-19   Boys  Girls    Affiliation: [AYSO]    [USYSA]    OTHER:_______

AYSO- S/A/R: ____/_____/______ USYSA- Reg./State/Club: _____/_____/____________________

Team Name: __________________________ Colors: Jersey: ______  Shorts: ______ Socks:______

	name	e-mail	cert. level	phone	local phone
Head Coach
Asst. Coach
Center Referee
Asst. Referee
Asst. Referee

List players in order of their jersey number

	Jersey	Player Name	Age	Date of Birth	Player registration number (club I.D.)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18

As (Head League Administrator/Regional Commissioner) of (league name/region #) _____________________________, I have reviewed the above information and I hereby certify the accuracy of the information listed and that the listed players and coaches are registered members of the organization that I represent.

Signature:_______________________________ Position Title:__________________ Date:_________________

Mail roster in no later than June 12, 2004 to: