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 21th - 25th Week#2 June 28nd - July 2rd Week#3 July 5th - 9th Week#4 July 12th - 16th Week#5 July 19th - 23th Week#6 July 26th - 30th Week#7 August 2nd - 6th Week#8 August 9th - 13th
Other. Please detail program required if different than options above. (i.e. - daily):	Anti Keylogger