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
U10coed -  6 Field Players and a Goalie		1.Three Coaches and rostered players
U12coed -  5 Field Players and a Goalie		    only on the bench.
U14coed -  4 Field Players and a Goalie		2. Team designated as Visitors will change
U16girls  -  4 Field Players and a Goalie		    shirts if there is a jersey conflict.
U16coed -  4 Field Players and a Goalie

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 Anderson Jr., -Coed/Boys Director125 Bellevue DrivePittsburgh, PA 15235412-793-3433 (After 9:00 PM)	Kim Anderson, - Girls Director125 Bellevue DrivePittsburgh, PA 15235412-793-3433 (After 9:00 PM)