Korich Kristopher is applying to register with Kokomo Mantis FC for the 2016 PDL season. He is a 24-year-old U.S. citizen from Upland, California who last played for Real So Cal FC in the Coast Soccer League in February 2016. He graduated from Cal Poly Pomona in 2015. Kristopher currently has personal health insurance and is aware that the team's insurance will act as secondary coverage.

1. G3h 2016 PDL Amateur Registration
Club Name: Kokomo Mantis FC
PLAYER BIOGRAPHICAL INFORMATION: (complete aU sections)
Korich Kristopher
Last Name
20128 Padrino Ave
First Name
Walnut CA
Middle Initial
91789
Current Address
9094555548
City State
kris.korich.7@gmail.com
Zip
Phone Number E-MaU
N/A
DateofBiith:
12/01/1992
Twitter Handle
Place of Birth (Nationality):
Upiand/CA USA
Month/DayA^ear City/State Country
Citizenship: U.S. Citizen
Canadian Citizen
Permanent Resident Other
If other, please fill in
LAST CLUB/COLLEGE INFORMATION: (all information must be completed)
Club: (List last team, dab or youth club governed by FIFA regulations; NOT a college or university team)
Real So Cal FC Coast Soccer League USA
Last Team/Club Participated (Required)
02/14/16
League Country
Amateur
Date of Last Game Played
College: (List current college; it not applicable, enter N/A)
Cal Poly Pomona
Professional/Amateur
Name of College/University Division
2015
Graduation Year
If yes, current year in
College (as of Fall 2016):
College Ehgibihty?
FR SO
Yes
JR
No
SR
INSURANCE INFORMATION:
Yes, Player HAS Personal Health Insurance
Player currently has personal health insurance. Player is aware that the insurance offered by PDL team and United Soccer Leagues wiU act as
secondary insurance.
(InsiuMce Provider) (PoUcy #)
No, Player EHJES NOT HAVE Personal Health Instirance
Player does not currently have personal health insurance. Player is aware that the insurance offered by PDL team and United Soccer Leagues is
secondary insurance and may not provide fiill coverage for any injuries received while competing for said team.