Wisconsin Youth Soccer Association Center for Excellence Program
Secure Center for Excellence Application Form

Registration Fee: $50 (you may pay by e-Check or credit card)
All Center for Excellence fees and payments are non-refundable.
It's Secure! Wisconsin Youth Soccer uses Secure Socket Layer (SSL) technology to transmit your data to the web server.

Required Fields are Marked with a "*"
NOTE! All Center for Excellence information will be sent by email to the Email Address provided below.

Player Information
Player's Name* First Last
Birthdate* & Gender* mm dd yyyy   Boy Girl
Street Address*
City, State & Zip* ,   
Home Phone* ( ) -
Contact Email Address*
Confirm Email Address*
Position* Forward Midfielder Defender Goalkeeper
Are you a US Citizen?*
 Yes No
Developmental Program District
Current Club
Current Club Team
Current Club Team Coach
Current Playing Age Group
Parent/Legal Guardian Information
Mother's/Legal Guardian's Name
Mother's/Legal Guardian's Home Phone ( ) -
Mother's/Legal Guardian's Work Phone ( ) -
Mother's/Legal Guardian's Mobile Phone ( ) -
Father's Name
Father's Home Phone ( ) -
Father's Work Phone ( ) -
Father's Mobile Phone ( ) -
Alternate Email Address
Confirm Alternate Email Address
Medical/Insurance Information
Family Physician
Family Physician Phone ( ) -
Family Dentist
Family Dentist Phone ( ) -
Insurance Provider
Insurance Provide ID #
Promotional Release

I undestand that occasionally photos and/or video will be taken of the players to be used in promotional materials for Center for Excellence. I agree to allow my child's image to be used for non-profit promotional purposes.
Payment Information
Payment/Fee: $50
Please Select your Payment Method: Check Credit Card
For Credit Card
Credit Card #
Credit Card Exp. Date /
Name on Card
Cardholder's Street Address
Cardholder's Zip Code
For Check Payment

Bank Name
Bank Routing Number (ABA Code)
Bank Account Number

Account Holder Name

 

By checking the box at left, We hereby acknowledge and certify via electronic submission/signature that we are the parents/legal guardians for the player/participant listed herein. Further, We (player and parents/legal guardians) further agree to abide by the rules, regulations, policies and decisions of the Wisconsin Youth Soccer Association (WYSA).

  

Please click ONLY ONCE on the Submit button above. 
Sometimes, it takes a few seconds for the form to be processed. Thank you.