Participant's name Sex
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.
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