PHSA Autumn Ambush Soccer Tournament

Association Name ______________________________________  Age Group __________________

Coaches Name     _______________________________________  Shirt Color __________________

Phone Number      _______________________________________  Alt. Color  __________________

Age Limits:
U8coed   -  6 Field Players and a Goalie
U10 B&G -  6 Field Players and a Goalie		1.Three Coaches and rostered players
U12 B&G -  5 Field Players and a Goalie		    only on the bench.
U14 B&G -  4 Field Players and a Goalie		2. Team designated as Visitors will change
											    shirts if there is a jersey conflict.
											3. Please bring copies of Birth Certificates or Player 
												Passes in case players age is in question.

Please Print							PARENT/GUARDIAN 
PLAYERS NAME 		BIRTH DATE	CLUB AFFILIATION	 SIGNATURE		

1					:			:				:			

2					:			:				:			

3					:			:				:			

4					:			:				:			

5					:			:				:			

6					:			:				:			

7					:			:				:			

8					:			:				:			

9					:			:				:			

10					:			:				:			

11					:			:				:			

12					:			:				:			

*Please use other side of the Roster Form if you plan to Roster more than 12 players. Also, note that 
only 10 trophies will be given by PHSA, NO EXCEPTIONS.

I/We assume all risks and hazards incidental to the conduct at the tournament for my/our child. I/We 
understand that the PHSA and Penn Hills School District does not insure My/Our child and that such 
insurance for any accident, injury or liability is My/Our responsibility. I/We do further hereby release, 
absolve, indemnify and hold harmless the PHSA, Penn Hills School District and their regular Affiliates, 
Organizers, Sponsors and Supervisors, any and all of them. I/We also understand that the behavior of 
My/Our child at Penn Hills School District Facilities is My/Our responsibility and I/We will be financially 
responsible for any willful Damage, Alteration, Theft or Loss done by My/Our child to Equipment or 
Facilities of the Penn Hills School District.

Carl and Kim Anderson, Tournament Directors
125 Bellevue Drive Pittsburgh, PA 15235
412-398-0479  or  412-600-3080