Request for Certificate of Insurance
Provided by Missouri Youth Soccer Association
Name of Person requesting *
Your answer
Name of Club or League a member of *
Your answer
Name of Team *
Your answer
Gender of Team *
Age Group (birth year) of Team *
Your answer
Name of Facility to be covered in COI *
Your answer
Full address of Facility to be covered in COI *
Your answer
Special Instructions:
Your answer
I understand that COI's do not cover a private residence or property not designed for soccer *
Required
I understand that this does not provide coverage for fields with "walls" (i.e. dasher boards as found on indoor soccer fields) *
Required
I affirm that all players participating are registered with Missouri Youth Soccer Association *
Required
I affirm that I am in possesion of a fully executed USYS Medical Waiver for each participant *
Required
Your e-mail for Certificate to be sent to: *
Your answer
Contact Phone Number: *
Your answer
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