Missouri Permission to Participate Form This form must be

Missouri Permission to Secondary Roster Form
This form must be completed and signed by all parties for acknowledgement & authorization of a youth
player to secondary register with another team outside of their own club during a seasonal year.
Both clubs are responsible for securing and retaining a copy of this document, the Secondary Club is
responsible for sending a fully signed copy to the State Office prior to rostering of player. Any
misrepresentation made on this document can result in coach/parent/player suspensions of up to one year.
Name of Player: ___________________________ DOB: _______ ID# ________________
Current Club: ________________________________________ Age/Gender: ________
Primary Rostering Team of Player: ________________________________
Primary Coach Name: ____________________________ Phone: _____________________
Club/ Team Seeking Secondary Roster: ________________________________________
Secondary Club Coach Name : _________________________________________ (print)
Phone: ___________________ Seasonal Year: ________________________________
By signing below I verify that all information above is accurate and acknowledge that the player has permission to secondary roster
with another club. I understand that this permission does not grant or authorize a player transfer.
Primary Coach Signature: __________________________________________ Date: ____________
Primary Club Registar Signature: ____________________________________ Date: ____________
Secondary Club Registar Signature: _________________________________ Date: _____________