Individual Enrollment Form

Please complete the section below and then proceed to the Secure credit card *PayPal* Payment Center.

Payment can also be made by *Check*.

Last Name: First Name:
Street:
City:
State: Zip:
Players Birth Date: Male Female
Home Phone (incl. area code): Cell Phone (incl. area code):
Parent Home Phone (incl. area code): Parent Cell Phone (incl. area code):
Parent Email:

MEDICAL AND EMERGENCY INFORMATION:

Insurance Co.:
Policy #:
List Medical Problems/Medications:
Other emergency contact:
emergency phone #:
Relationship to player:
Select the dates:
- It is possible by arrangement, to attend multiple sessions per week.
- Sessions are normally held once a week and are 1.5 hours long.Fee per player:

12 sessions is $1,800.

ALL PROGRAMS ARE ROLLING ADMISSION ! You can sign up for a program that has commenced – subject to availability.

* If you are registering late, please enter the START-DATE:
SUNDAYS: (12 Sessions) MONDAYS: (12 Sessions) TUESDAYS: (12 Sessions) WEDNESDAYS: (12 Sessions)
THURSDAYS: (12 Sessions) FRIDAYS: (12 Sessions) SATURDAYS: (12 Sessions)
Select the time of the day you prefer: (a second option may be required)
9a 10a 3p 4p 5p Other
If Other Time, then Please Specify
Player level/experience:
Have you attended a World Soccer Program before?:
How did you hear of World Soccer?:
USE THIS SPACE IF:
You have any questions or comments. Or if you need registration forms mailed to you.
IMPORTANT!World Soccer, coach/organization/venue/independent contractor shall not be held responsible for any injury to a player occurring during a session. It is understood that players are insured independently or through their respective teams and clubs.

Make up sessions by prior arrangement! There is a no refund policy. Refunds only apply if World Soccer cancels a session and cannot reschedule a makeup.

If in agreement with the above terms, enter your name here: