2008 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 to:

     Louisiana Soccer Academy, LLC

     42277 Autumn Dr                                                            

     Hammond, LA  70403