U.S. YOUTH SOCCER - REGION IV OLYMPIC DEVELOPMENT PROGRAM 
           "REGIONAL PLAYER POOL" ASSISTANCE FORM

  This application must be submitted to the Region IV Office no 
    later than 45 days before the scheduled event to be valid.

  Financial assistance is available, based on individual necessity,
for all eligible pool players participating in the Region IV Olympic 
Development Program. Please complete the information requested in detail.
It is important that you contact your club and your state association for 
financial assistance before requesting assistance from Region IV as this 
documentation must be provided for your application to be considered.

                      PLEASE TYPE OR PRINT CLEARLY                          

PLAYER NAME: ___________________________________ BIRTH YEAR: _______________

PARENTS NAME: ______________________________________________________________

ADDRESS: ___________________________________________________________________

CITY: ____________________________ STATE: ____________ ZIPCODE: ____________

TELEPHONE: (H) ______ ______ - ___________   (W) ______ ______ - ___________

STATE ASSOCIATION: _________________________________________________________

CLUB TEAM: _________________________  TELEPHONE: ______ ______ - ___________
                                                                            
        PLEASE LIST THE EVENT AND FUNDING ASSISTANCE YOU ARE REQUESTING.

EVENT: ______________________________________  EVENT COST $: _______________
Region IV holdover pool camp, interregional event, international event, etc.

FINANCIAL ASSISTANCE REQUESTED $: _______________
                                                                            
         Please list any matching funds you can provide or other 
     funding you may have received and by whom they were provided.

SOURCE: ____________________________________  AMOUNT $: ______________

SOURCE: ____________________________________  AMOUNT $: ______________

SOURCE: ____________________________________  AMOUNT $: ______________
                                                                            

PLEASE PROVIDE A BRIEF WRITTEN RATIONAL FOR THE FUNDING REQUEST ON THE 
BACK OF THE APPLICATION. (You may attach and additional information you 
feel would be helpful to your request.)
                                                                            
                            FOR OFFICIAL USE ONLY                         

FUNDING APPROVED: $ ______________________  COMMITTEE: _____________________

ODP ADMIN: _______________________________  DIRECTOR: ______________________
                                                                            

Send this application and required documentation to: 
                    
  USYS - Region IV, 5600 W Spring Mountain #110, Las Vegas, NV 89146