for boys & girls aged 6-12
November 2010 /
participant application form - PLEASE PRINT CLEARLY
First Name: Last Name:
Street Address:
City: Zip Code:
Home Phone: ( ) - - Date of Birth: MM / DD / YYYY
Medical Conditions: Gender:
E-Mail:
Emergency Contact:
Phone # 1: ( ) - - Phone # 2: ( ) - -
Course Information: Please check box accordingly
Gender: Boys ¨ Girls ¨ Age As At 11/1/10
Day: Monday ¨ Tuesday ¨ Wednesday ¨ Friday ¨
Price: $25 ¨ $35 ¨ $45 ¨
Time: 4:15–5:15 ¨ 5:30 – 7:00 ¨
Payment Method: Cash ¨ Check ¨ Credit Card ¨ Check #
As the parent/legal guardian of the above-named player, or player age 18 or over I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of my dependent. I agree to hold harmless 24-7 UK Soccer Academy, 24-7 Futsal Academy and Futsal Republic and it agents and employees and hereby release them from any liability on account of injuries sustained by the player while participating in any activities. I give consent for the above player to be photographed, videotaped or filmed while participating in any soccer activities and the resulting photos / film to be used by the 24-7 UK Soccer Academy, 24-7 Futsal Academy and Futsal Republic and its agents and employees for educational and promotional purposes. I have read and understand the above.
Signature of Parent/Legal Guardian: Date / /
PLEASE NOTE ONLY 18 PLAYERS PER SESSION – SO BOOK NOW
$ Discount Applies If Application Received Before November 5th 2010.
FOR CREDIT CARD PAYMENTS AND COURSE INFORMATION VISIT
www.futsalrepublic.com or www.24-7uksocceracademy.com
Checks should be made payable to 24-7 futsal academy and sent with a completed application form to: 24-7 FUTSAL ACADEMY, 4061 E. CASTRO VALLEY BLVD #447, CASTRO VALLEY CA 94552.
please put your childs name, day attending and age in the memo section of your check
For Offical Use Only
Date rec: / Paid / Group / Confirmed