Instructional Application

Participant's name                                                            Sex           

Address                                                       City,State,Zip                             

Home Phone                                   cell                          

Birthdate                            Age           Email Address                                


Children will need to bring a ball (We have them available for $10.00 if needed)

  The above named applicant is in good health and has my permission to participate in this program. In case of emergency, I grant my permission for my child to be given emergency medical treatment. I hereby release Midwest Soccer Academy and staff from all liability for any injury or illness incurred while in the program, which includes the place of treatment of said injury or illness. I agree to assume complete financial responsibility for any personal injury or property damage caused as a result of an intentional or negligent act of my child while enrolled at the Midwest Soccer Academy program or upon the premises of the program while participating in any activities.

Parent/Guardian                                                  Date                       

Please download and send in your payment to: Midwest Soccer Academy, 5247 Fyler, St. Louis, Mo. 63139 or enter your charge information and submit, please note: There is 5% surcharge for all charge payments.

Charge            Charge Number                                Exp.Date                 
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