2010 Louisiana Soccer Academy
Application
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: __________________________
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 $50.00.
Balance is due at registration.
MAKE CHECKS PAYABLE AND MAIL TO:
Louisiana Soccer Academy, LLC
42277 Autumn Dr
Hammond, LA 70403