Registration Form

Event Registration for JBSA Soccer Camp 2011 (8/1/11 - 8/5/11)

The Jeremy Beardsley Soccer Academy is designed to develop, improve, and prepare the serious soccer player for success. Players will receive valuable exposure in a competitive and enjoyable environment. Costs: Full Academy $310 before 5/1, $335 after 5/1, Academy Cadets $150
JBSA Soccer Camp 2011 (8/1/11 - 8/5/11) - Cost $ 310.00

Player First Name:

Player Last Name:

E-Mail:

Phone:

Street:

City:

State or province:

Zip:

Male/Female

Age

Date of Birth (mm/dd/yy)

Club Team

Spring 2010 Level U-

Mother/Guardian Name

Daytime Phone

Father/Guardian Name

Daytime Phone

Cell Phone

Other Emergency Contact Name

Relationship

T-Shirt Size

Soccer Ball Size

Position


Program you are attending


Allergic Reactions


To What?

Taking any medications currently?


Please list

Any other pertinent medical information

Insurance Company

Policy Number

Name of policy holder

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