1. Athletes, please fill out the following registration form to register for the 2009-2010 Power Soccer season.
   
   
2. After submission of this page, you will be sent to another page to fill out the USPSA Code of Conduct. You must submit both forms before your registration will be accepted! If the second form is not filled out, your data will not be saved, and you will have to start over.
   
   
3. The USPSA Waiver (for insurance purposes) and registration fees must still be submitted via postal mail. Mail all team waivers in one package. Download the USPSA Waiver here.
   

Fields with an asterisk * are required. The form will not submit unless these fields are filled out and verified. If they are not valid values, you will see a red box and red asterisk around the field. Correct these items before submission.

This form uses image verification to stop automated spam bots. Enter the bold text (case sensitive) before submitting the form. The form also uses JavaScript and session cookies for security, so please make sure these are enabled in your browser. If you are having difficulties seeing the image, contact the IT Committee at This e-mail address is being protected from spambots. You need JavaScript enabled to view it and they will help.

Note: This is not a contact form. To contact a team in your area, review the D1 map and the D2 map, and go to the list of Team Contacts.

Athlete Registration

 

Team Name* Choose... Arizona Heat 2nd Degree Arizona Heat 3rd Degree Atlanta Tigers Ball State Cardinals Ball State Fury Bennett Blazers Gold Bennett Blazers Red BORP Bay Earthquakes BORP Bombers BORP Crushers Brooks Barracudas Carroll County Dominators Charlotte Power Surge Chattanooga Speeders Circle City Rollers CNY United Courage Blizzards Blue Courage Blizzards White Courage Thunder Courage Tornados DASA Dynamites DASA Firecrackers Driving Force GJL Louisiana Lightning Hawks GLASA Chicago Fire Glendale Roughriders Glendale Wild Wheelers Henry County Hot Shots Hollister Free Wheelers Indy Storm Jackson Jammers Jr. Red Bulls Kokomo Spinners Lakeshore Power Madison Marauders Magee Kixx MHS Chariots NEW TEAM UNLISTED Newark Hot Rodders North Georgia Screamin' Eagles Northeast Passage Power Cats Orlando Hurricanes RHI Indy Cruisers RHI Inferno RHI Sudden Impact Rochester Speed Demons Rockford High Voltage Royalty San Jose Steamrollers San Jose Steamrollers Express Santa Barbara Rollin' Gauchos Santa Barbara Rollin' Rebels Shepherd Strikers SLO Dragons Synergy Tampa Bay Crossfire Tampa Thunder Tidewater Piranhas Blue Fish Tidewater Piranhas Red Fish Tucson Power Cats Turnstone Flyers Turnstone Furious Flyers

 

First Name*

 

Last Name*

 

Address*

 

City*

 

State* Choose... AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA RI SC SD TN TX UT VA VT WA WI WV WY

 

Zip Code*

 

Phone Number* - - x

 

E-mail Address*

 

Other Contact

 

Birthday* Month January February March April May June July August September October November December    Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31    Year 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Older

 

Gender*

M F

 

Disability* Choose... Amputee Arthrogryposis Ataxia Brain Injury Cerebral Palsy Duchenne Muscular Dystrophy Muscular Dystrophy Multiple Sclerosis Osteogenesis Imperfecta Other (Please Specify) Paralysis Post-Polio Paraplegic/Quadraplegic Spinal Muscular Atrophy Spina Bifida Spinal Cord Injury

 

Primary Method of Mobility* Choose... Manual Wheelchair Motorized Wheelchair Walking with Aid (i.e. walker, cane..) Walking without Aid

 

Wheelchair

 

Comments

 

Image Verification*