Team Name ___________________________________________ Association ____________________________

Coach ________________________________ Telephone (Hm) _________________ (Wk) _________________

Address ______________________________ City ____________________ ST ______ Zip ______________

Team Manager _________________________ Telephone (Hm) _________________ (Wk) _________________

Address ______________________________ City ____________________ ST ______ Zip _______________

Date of Proposed Game _______________________ Location _________________________________________

Name of Unaffiliated Team _________________________________ Coach ______________________________

Address ______________________________ City ____________________ ST ______ Zip ______________

Contact Telephone __________________________ Insurance provided by ________________________________

Reason for Request ____________________________________________________________________________

Requirements for Approval:

1.                    Properly and legibly completed application per event

2.                    $10 processing fee per application

3.                    Copies of Medical and Liability Insurance of opposing team

As a coach of this team requesting permission to play an unaffiliated team, I understand that we may not play this team again during this seasonal year without permission and that my team and I will abide by the TS Code of Conduct. I also understand that this form must be in the State Office seven (7) days prior to the scheduled game. Any infraction to the TS, USYS, or USSF policies may result in my team and I being placed in bad standing.

Signature of Coach ____________________________________________ Date ___________________________

Local Association Approval _____________________________________ Date ___________________________

Title of Approving Officer (print) _________________________________________________________________

Tennessee Approval

Approved _________ Not Approved __________ Comments _________________________________________

State Registrar Signature ________________________________________ Date __________________________

5/29/01