Emile Mbouh Soccer Academy : Team Coaching - Private Sessions

EmileStarSoccer.com

Registration Form

Click here to download the printable registration form.


* Applicant's First Name
* E-mail Address:
* Applicant's Last Name
* Age
* Sex
* Address
* City
* State
* Zip Code


* Parent/Guardian's Full Name
* Home Phone
* Work Phone
* Mobile Phone
* Email Address


* Program Name
* Program Title
* Location
* Manager Name
* School Name
* Season
* Date


Please describe any medical problems that participant has (if any)
Other Comments
Program Fee : $

Liability Waiver As a participant in a program run by Emile Star Soccer, my son/daughter is in good health and has my permission to participate in the soccer program. emile star soccer, and its directors, employees and the facilities assume no responsibility and will not be held liable for any injuries and illness, accident will at the camp resulting in medical, dental or other expenses. I also give Emile Star Soccer permission to use my child’s name and or picture in promotion of the camp/program in printed media and another forms of advertisement. I fully renounce all claims upon emile star soccer for reimbursement for the use of this material * * I agree.


* Required Field