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Youth Module 1 Application Form Youth Module I
12pm to 5pm
Sunday June 22, 2008
Westminster SA – Carroll Community College
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 Westminster Soccer Assn., to act according to their best efforts and judgment in any emergency requiring medical attention and I hereby waive and release MSYSA or the Westminster Soccer Assn., 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_______________________________________
Mail with $40 fee to: Linda Craig Phone (410) 987-7898
Payable to MSYSA PO Box 667 coursecoord@msysa.org
Fax-(410) 987-8707 Millersville, MD 21108 or Bill Warburton (410) 848-6850
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