2010 Louisiana Soccer Academy

Application

___ Resident ___Commuter ___Half Day ___Full Day

Name: ___________________________________

Address: _________________________________

City: _____________ State: _____ Zip: _________

Email: ____________________________________

Age: _____________    Boy  /  Girl  (Circle One)

Soccer Position: _____________________________

Team/Club: ________________________________

Parent Name: _______________________________

Parent Phone: (H)___________ (W)______________

(Cell)_______________ (Pager)_________________

Emergency Contact: __________________________

Emergency Number: __________________________

Roommate Preference: ________________________

T-Shirt Size: S  M   L      XL      Youth/Adult

(Please Circle Size AND Youth or Adult)

To complete this application, please remit this form containing the insurance

waiver agreement and physician release with a non-refundable deposit of $75.00.

Balance is due at registration.  

MAKE CHECKS PAYABLE AND MAIL TO:

Louisiana Soccer Academy, LLC

42277 Autumn Dr

Hammond, LA 70403