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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