Francis Okaroh's Ultimate Soccer Academy Registration Application
April Vacation Soccer Blast April 21-25, 2008 Mon- Fri for Boys & Girls ages 6-14
 
Name(s) :
 (1) ________________________________________ Current grade :   ___________  Gender:  ____
 (2) ________________________________________ Current grade:    ___________  Gender:  ____        
 (3) ________________________________________ Current grade:    ___________  Gender:  ____
               
Address:  _____________________________________________________________________________
 
City:  ____________________________     State:  ___________________     Zip:  __________________
Email:  __________________________________
Contact Information
 
Parent Name(s):  _______________________________________________________________________
Daytime Phone:  ______________________                           Other Number:  ______________________
 
Insurance Information
 
Medical Insurance Carrier:____________________________             Policy#______________________
Medical Conditions or Special Needs? ….Please describe any medical conditions or special needs we should be aware of (use back of form for extra space):
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INJURY WAIVER: I hereby absolve the town of Dover Sherborn including all coaches, managers, officers, and others participating in league activities from all liability and will not hold them responsible for injury incurred to the registered person(s) and hereby give my approval to participation in this program. It is my understanding that coaches have the authority to suspend registered players for poor behavior detrimental to the purposes of the program.
Parent Signature    :___________________________________   Date:   ____________
 
Please indicate your choice for shirt/ball sizes in the box below: (If you have more than one camper attending please indicate sizes for each camper)  Campers that register late may not get their desired sizes. 
Available sizes:
 
T-Shirt Size (Youth Sizes): Small                    Medium                 Large                      X-Large
 
T-Shirt Size (Adult Sizes): Small                     Medium                 Large                     X-Large
 
T shirt:    Size(s):  _____________,                 ______________,             _______________
 
Ball:  (Circle one)                               SIZE 4    __________                         SIZE 5  __________
 
Check the correct boxes that apply:
 
         Half Day (9:00 am – NOON)  $180                        Full Day (9:00 am- 4:00pm )   $360
         Late fee $20 For registrations after MARCH 16, 2008
Discounts for each additional family member:
         $150 for Half Day Session for each additional Family Member
         $300 for Full Day Session for each additional Family Members
 
Amount Enclosed  $  _____________                                                          Total Number of Campers:  ______________
Make Checks Payable To: Francis Okaroh
Mail Registration forms to: 23 Paquin Drive, Marlborough, MA 01752