USASA Field Certificate of Insurance Request Form

USASA Field Certificate of Insurance Request Form
State Association:

Massachusetts State Soccer Association
Who is making this request?

Identify yourself, your league, and team.
Name *

First Name Last Name
Mass Soccer ID: *
Mass Soccer Affiliated League: *
Team Affiliation *
Which Division? *
Required for NEOTHSL. N/A for others.
Facility or Field Owner

Who owns the field that you are reserving? (Typically this is a city, town, or sometimes a private company or private school.)
Who owns the field? *
Town or city recreation department or university/college

Address of FIELD OWNER (Not usually the address of the field.) *

Field Information

What field/s are you requesting?
List facility/fields your are requesting: *
ie: Alpine Field, Middle School, High School Turf
Phone Number

- Area Code Phone Number
Please email the proof of insurance certificate to:
Attention: *

First Name Last Name
E-mail: *
Should be Empty:

State Association: