Coerver Coaching Connecticut: Youth Soccer Coaching At Its Best

Application Form
Residential Camp A: Premier
Mitchell College, July 22 – July 27, 2006 6 days/$675

Personal Information:

Player's first name:
Player's last name:
Player's age at camp:
Player's date of birth:
Player's sex:		Male Female
Type of Player:		Field Player Goalkeeper
Address:
City:
State:
Zip:
Current level of playing experience:		Recreational Travel Premier High School Other

Parents' first names:
Parents' last name:
Home phone:
Work phone:
E-mail:
Family physician:
Physician's phone number:

Player's T-shirt size		Youth: S M L Adult: S M L XL

If Applicable:

Roomate request (if possible):
Team or group:
Coach's name:
Coach's day phone number:
Coach's evening phone number:

	Discounts Note: Only one discount may apply

	Check the discount that is applicable. Discounts will be deducted from the balance due. Discounts cannot be combined, one discount each session.

	Sibling

	Deduct $25 for each additional sibling

	Team (a group of 10 or more)

	Deduct $25 for each player

	PLEASE NOTE: ONLY ONE DISCOUNT CAN BE APPLIED

Please select Full Payment or Deposit

Full payment or a deposit of $250 per session is required to register.

.

Full payment

Deposit ($250)

Amount of payment:

Please note: For your protection and privacy all information is being transferred through a secure server.

All payments by personal check should be received by Coerver Coaching within one week of submitting this application and at least seven days prior to the start of the Coerver Coaching session.

Make checks payable to Coerver Coaching and mail to:
Coerver Coaching
58 Hawks Hill Road
New Canaan, CT 06840

Please Select a Form of Payment

						Personal Check

If you are using a credit card, please enter the information requested. If you are paying by personal check, please leave the boxes filled with "No card, personal check."

Card number (xxxx-xxxx-xxxx-xxxx):

Name as it appears on the card:

Expiration date on card (xx/xx):

How did you hear about Coerver Coaching?

For more information call 203.966.8081 or email Coerver Coaching Connecticut now at djohnson@coerversoccer.com! © 2007, Five Star Holdings, LLCReturn to top