FUTSOC USA - Registration

FUTSOC Summer Soccer Program
Registration Form

Participants Name:
Sex:	Male Female
Age:
Birth Date:
Grade:
School:
Experience Type:
Experience (Years):
Insurance:
Insurance Phone:
Physician:
Physician Phone:
Medical Condition	Yes No
If so, please list condition along with any applicable medication(s):
Mother / Gaurdian:
Email:
Work Phone:
Cell Phone:
Home Phone:
Place of Employment:
Home Address:
Mother Permitted to pick up participant:	Yes No
Father / Gaurdian:
Email:
Work Phone:
Cell Phone:
Home Phone:
Place of Employment:
Home Address:
Father Permitted to pick up participant:	Yes No
Other individuals authorized to pick up camp participant(s):
#1:
Phone Number:
#2:
Phone Number:
Half day or Full day:
Specify Plan:
Weeks Participating (Check All that Apply):	Week#1 June 8th - 12th Week#2 June 15th - 19th Week#3 June 22nd - 26th Week#4 June 29th - July 3rd Week#5 July 6th - 10th Week#6 July 13th - 17th Week#7 July 20th - 24th Week#8 July 27th - 31th Week#9 August 3rd - 7th Week#10 August 10th - 14th
Other. Please detail program required if different than options above. (i.e. - daily):	Anti Keylogger