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2009 La Academia de Futbol Registration Form
INSTRUCTIONS:
Please return this registration form
(completed fully & signed by Parent/Guardian & Player) with
your 1st payment
of $500 USD REFUNDABLE
(Up to 30 days prior to departure).
You can either mail or fax this form. Space is limited. It is
recommended that you register now.
You will receive additional program information from La Academia
Inc. via email upon receiving this completed 2009 registration form.
PARENT INFORMATION (Please Print )
Parent / Guardian Full Name:
____________________________________________________________________________________
Mailing Address:
____________________________________________________________________________________________
City, State or Province:
________________________________________________________________________________________
Postal Code, Country:
_________________________________________________________________________________________
Home Telephone: ( )_____________________Cell: (
)_______________________Work: ( )
__________________________________
Email
(mandatory):____________________________________________________________________________________________
Emergency Contact Name:
______________________________________________Relationship:
_____________________________
Emergency Contact Telephone: (
)_______________________________________Email:
____________________________________
Please briefly explain what you
hope your child will accomplish with La Academia:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
PLAYER INFORMATION
Full Name (as it appears on your current passport):
___________________________________________________________________
Mailing Address:
____________________________________________________________________________________________
Passport # & Issuing Country:
______________________________________________________ Exp. Date: _________________
E-mail:_______________________________________ Date of Birth: ____ /____ /____ Age:______ Gender: □ Male □ Female
Soccer Position(s): □
Striker □ Mid-fielder □ Defender □ Goalkeeper – Years
Played: □<4 yrs □5-6
yrs □7-8 yrs □9 yrs+
Adult T-Shirt Size: □ Small □ Medium □ Large □ X-Large -- Foreign Language Level: □ Beginner □
Intermediate □ Advanced
Please indicate any medical
condition (i.e. Allergies, Asthma, Illnesses, Previous Injuries, etc.) or any “Special Instructions”
here:
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Roommate Request: □No □ Yes - If yes, name of friend:
________________________________________________________________
Favorite player, interests &
hobbies:_____________________________________________________________________________
__________________________________________________________________________________________________________
Briefly explain what you hope to
accomplish with la Academia: __________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
TUITION PAYMENT SCHEDULE:
Payment #1: $500 USD . Due now. Serves as deposit (refundable up to 30 days
prior to departure).
Payment #2:
$1500 USD Due before April 15, 2009
Payment #3:
The remaining $1100
USD Due before June 1, 2009
DEPOSIT PAYMENT #1:
Please choose payment method for Deposit Payment #1 &
Registration Fee:
□ CHECK: Enclosed is my deposit check or money order made payable to “Adrian International” in the amount of _________________USD.
□ CREDIT CARD: Please charge my: □ VISA □ MasterCard
□ WIRE TRANSFER:
I will wire transfer the deposit payment to: Contact La Academia for bank
information.
Credit Card Account Number: ____________________________________________________________ Exp. Date: ____/____
mm yy
Cardholder Full Name:
_________________________________________________________________________________________
Mailing Address (associated with this credit card):
___________________________________________________________________
BALANCE PAYMENTS #2 & #3: Please choose payment method for your two additional payments:
□ CHECK: I will send personal checks or money orders
□ CREDIT CARD: I authorize you to charge my □ VISA □ MasterCard
□ on the due
dates.
PAYMENT IN FULL:
□ Please find my enclosed tuition payment in full – Payment
Method: □ CHECK: □ CREDIT CARD: □ BANK WIRE
TRANSFER
2009 Registration Form
– Page 3
RECOGNITION AND ASSUMPTION OF RISK
AGREEMENT& PHYSICIAN RELEASE
I, the undersigned parent/legal guardian of (player’s full
name)_______________________________
authorize said child's full participation in La Academia de Futbol
Internacional 2009 and related language/soccer camp activities. It
is my understanding that participation in the activities that make
up La Academia de Futbol Internacional 2009 is not without some
inherent risk of injury. As such, in consideration of my child's
participation in the selected La Academia de Futbol Internacional
2009 Program, I hereby release, waive, discharge, and covenant not
to sue the La Academia de Futbol Internacional, Christopher
Adrian, Adrian International, servants, agents or employees from
any and all liability, claims, demands, action, and causes of
action whatsoever arising out of or related to any loss, damage,
or injury, including death, that may be sustained by my child,
whether caused by the negligence of the releases, or otherwise
while participating in such activity, or while in, or upon the
premises where the program activity is being conducted.
I also give my permission for any emergency medical care or
treatment by a physician, surgeon,
hospital, or medical care facility that may be required, including
transportation, and accept
responsibility for the cost. I also understand that a medical
insurance policy carried by La Academia de Futbol Internacional,
Christopher Adrian, and/or Adrian International , if
any, will provide only minimum coverage and that I should make sure
my child is covered with
family insurance in the event of a serious accident. I also
understand and agree that if my child (dren) violates any of the
camp rules or regulations (included in the pre-departure packet)
that he/she may be sent home early at your own expense.
Print Player's Name:
_______________________________________________________________
Print Parent/Guardian Name:
________________________________________________________
Personal Health Insurance Company:
__________________________________________________
Insurance Policy Number:
___________________________________________________________
Parent/Guardian Signature: ________________________ Date:___________________________
I, ___________________________________, (player’s full name) have
read and agree to follow all instructions and procedures as
outlined on the La Academia de Futbol Iinternacional “Policy”
webpage in order to maintain a maximum level of safety and
security. I understand that if I violate any of the camp rules (to
be included in the pre-departure packet), La Academia de Futbol in
the person of director, Christopher Adrian, reserves the right to
send me home early at my
own or my parent’s expense.
Player's Signature: _______________________________ Date:
____________________________
Nationality & Passport #:
____________________________________________ Exp. Date: ____/____/____/
Fax to: 1- 269-353-8511 (you will receive email confirmation of
receipt within 24 hours)
Phone: Please feel free to call with any questions! 1-269-217-8601
Email: Please feel free to email with any questions: cadrian@kzoo.edu
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