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Application for "E" Course License
U.S.S.F. “E” COURSE
8:30am to 6pm both days
Please Circle One
Maryland SoccerPlex in Boyds - July 12 & 13, 2008
Chancellors Run Park in Lexington Park - July 19 & 20, 2008
Queen Anne’s County ISC in Centreville – August 9 & 10, 2008
Windsor Farm Elementary in Arnold – August 23 & 24, 2008
APPLICATION FORM
NAME___________________________________________ AGE_______
ADDRESS____________________________________________________
CITY_____________________STATE____ZIP______________
PHONE: HOME ( )______________OFFICE_________________________ E Mail _________________________________________________________ Club Affiliation__________________________________________________
Please read this waiver carefully, and then complete it: “I hereby authorize the staff of MSYSA or the sponsoring host organization, to act according to their best efforts and judgment in any emergency requiring medical attention and I hereby waive and release MSYSA or the sponsoring host organization, from any and all liability for any injuries or illness incurred while attending the course. I have no knowledge of any physical impairment that will affect my participation.”
Date__________________Signature_______________________________________ Coaches of MSYSA Affiliated Club Teams are deemed Members
MSYSA Members $85 - Non Members $100 Phone (410) 987-7898 Payable to MSYSA Fax-(410) 987-8707 Mail To: Linda Craig
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