Registration Form (one per family)
Please indicate Names of registrants
Clinic Level
Name: ___________________
Name: ___________________
Price
$80
$80
Junior Level
Name: ___________________
Name: ___________________
Price
$100
$100
Advanced Level
Name: ___________________
Name: ___________________
Price
$125
$125

 

Parent/Guardian: _______________
Address: _____________________
_____________________________
_____________________________
Phone: _______________________
Emergency Contact: _____________
Phone Number: _________________

Personal Statement & Disclaimer (Your signature is required);
Soccer is a strenuous activity and participants should engage in conditioning program and see their doctor before participating. By submitting this application, I agree not to sue Fundamental Soccer Academy, Reza Kaliush or St. James Academy in the event of injury or accident while engaging in this activity. I assume all risks associated with this activity.
Signature
__________________________________

Make Checks Payable to:
Reza Kaliush
929 Zenith Drive
Freeland, Md. 21053
Phone: (410) 913-9395
Email: fundamentalsoccer@comcast.net