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