1st Touch Soccer

ONLINE REGISTRATION FORM

1st Touch Soccer Academy , LLC

P.O. Box 99 , Ono , PA 17077 | Telephone: (717) 507-3392 | http://www.1sttouchsoccer.net

Participant's Name:
Age:
Gender:
Parent(s)/Guardian(s) of Participant:
Parent(s)/Guardian(s) of Participant:
Address:
City:
State:
Zip:
Emergency Phone:
Home Phone:
Cell Phone:
Email:

Please check the session you would like to attend:
5-7 year old boys and girls (10 weeks)		11-13 year old boys and girls (10 weeks)
	Fridays – January 4, 2008 – 7:00 to 8:00 pm – Court 3	X	THIS CLASS HAS BEEN SOLD OUT!
	Fridays – January 4, 2008 – 8:00 to 9:00 pm – Court 2	14 years and older boys (10 weeks)
	Sundays – January 6, 2008 – 3:00 to 4:00 pm – Court 3		Sundays – January 6, 2008 – 5:00 to 6:00 pm – Court 3
8-10 year old boys and girls (10 weeks)		14 years and older girls (10 weeks)
X	THIS CLASS HAS BEEN SOLD OUT!		Sundays – January 6, 2008 – 4:00 to 5:00 pm – Court 3
	Fridays – January 4, 2008 – 8:00 to 9:00 pm – Court 3	Goal Keeping (10+ year old boys and girls) (10 weeks)
	Sundays – January 6, 2008 – 3:00 to 4:00 pm – Court 2		Sundays – January 6, 2008 – 2:00 to 3:00 pm – Court 3

Participant's Insurance Provider/Carrier:
Policy Number:
Name of Participant's Physician:
Phone:
Special Conditions for Participant (e.g. medical, allergies, physical etc.)

I hereby certify that the above named participant is in good physical condition and capable of participation in strenuous physical activity and that all the above information is correct. I hereby give my approval for his/her participation in any 1st Touch Soccer Academy activities. I authorize the director, supervisor or coaches to act for me in their best judgment in any emergency requiring medical attention. I recognize that insurance coverage on any injuries to the participant received during or in connection with 1st Touch Soccer Academy activities is the responsibility of the parent(s) or guardian(s) insurance policy.
By typing your full name below you are signing this registration form.
Signature of Minor Participant's Parent or Guardian :
Date Signed:

Cost is $99.00 for each participant. Please make checks payable to "1st Touch Soccer Academy."

Send payments to:

1st Touch Soccer Academy

P.O. Box 99 , Ono , PA 17077

Download Waiver (waiver must be signed and handed in at the beginning of the first session in order to participate)

1st Touch Soccer Academy ▪ www.1sttouchsoccer.net ▪ info@1sttouchsoccer.net