COERVER – COACHING at Wolf’s INDOOR SOCCER

PLAYER’S REGISTRATION FORM

January 5 – February 13, 2015

Registration Form 2015

 

Camper’s Name: ____________________________________________________ 

Address: ____________________________________________________ 

City:       ____________________________________________________ 

State:     ______________  Zip:      _______________ 

(Home # :)     ___________________  (Work #:)     __________________ 

E – Mail:    ____________________________________________________ 

Age: _______ DOB:  _____________    Gender: ____________ 

Tee Shirt Size: YS  YM    YL    AS    AM    AL 

Emergency Contact ________________________________________________ 

Phone Number       ________________________________________________ 

Program      Academy $160.00   Mighty Mite $90.00 or $160.00 For both sessions

 

Please make checks payable to Coerver® Coaching 

And Mail to:   Steve Gummer, @ 2399 Westport Circle, Marietta, GA, 30064. 

For more information please contact Steve on 678-362- 6255   coervercoachingga@gmail.com

Waiver Information

As parent / guardian of the above player , I agree to hold Steve Gummer, and other staff members and Coerver® coaching harmless for injuries and other incidents that may result in my child’s participation in the above activity and camp, Further more I have  current medical insurance coverage, agreeing to assume all responsibilities if such expenses arise for injury,

 

_____________________________________      _______

Parent /Guardian Signature                                        Date