Select the Illinois Youth Soccer Coaching Course for which you wish to register:
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Applicant's First Name:

Applicant's Last Name:

Street Address:

City:

State:

Zip:

Home Phone with Area Code:

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Work Phone with Area Code:

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Fax with Area Code:
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Type of Team You Coach (please choose one): 

Recreational  Travel  Other

Team Name:

Team Age Group (i.e. U12):

Team Gender:
Boys  Girls

Club Affiliation:

League Affiliation:

Describe any medical or physical disabilities:

Indicate certificates or other soccer licenses (type, level, number and name of issuing organization):

I, the above named applicant/participant, fully understand that each applicant/participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue Illinois Youth Soccer Association, its affiliated organizations and sponsors, their coaches, managers, employees and associated personnel, officers, directors, agents, including the owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Programs and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The applicant/participant has received a physical examination by a physician and has been found physically capable of participating in the Programs. I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasee from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasee because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee. I have read the above waiver/release and understand that I have given up substantial rights by agreeing to this release and agree voluntarily.

By submitting my registration to Illinois Youth Soccer Association, I understand and agree to the terms in this Liability Waiver.

Please type in your credit card information below. Your credit card will be billed the full amount of the Course Fee you have chosen at the top of this form. Should you later prove to qualify for the $25 Illinois Youth Soccer affiliate discount, you will be issued a credit for the discounted amount.

Course attendees receive the course appropriate manual and US Soccer Laws of the Game Made Easy. ‘D’ and ‘E’ attendees also receive Illinois Youth Soccer T-shirts.

IMPORTANT: To qualify for the $25 Illinois Youth Soccer affiliate course discount, a copy of the front and back of your current Illinois Youth Soccer affiliated league coach’s pass must be in possession of the Illinois Youth Soccer office prior to the course date.

‘D’ License Applicants must submit to the Illinois Youth Soccer Association office prior to the ‘D’ Course the applicant’s original photo and a copy of the applicant’s ‘E’ Certificate or ‘E’ Certificate Waiver. A digital file may be emailed to cep@illinoisyouthsoccer.org.

I certify that the information provided in my submission to Illinois Youth Soccer Association is complete and accurate. Unless the coaching course is canceled by the Illinois Youth Soccer office, I understand and agree that the course fees are not refundable and that course fees may be transferred to another Illinois Youth Soccer coaching course.

CAUTION: ANY ATTEMPT BY THE PERSON SUBMITTING THIS FORM OR ANY OTHER INDIVIDUAL TO DELIBERATELY DAMAGE ANY WEBSITE OR UNDERMINE THE LEGITIMATE OPERATION OF ILLINOIS YOUTH SOCCER ASSOCIAITON MAY BE A VIOLATION OF CRIMINAL AND CIVIL LAWS. SHOULD SUCH AN ATTEMPT BE MADE, ILLINOIS YOUTH SOCCER ASSOCIATION RESERVES THE RIGHT TO SEEK DAMAGES FROM SUCH PERSON TO THE FULLEST EXTENT PERMITTED BY LAW.