· Please fill it and mail it enclosing a check or money order to: Nicolae Piperea - 19 Perna Lane - Stamford, CT 06903
· Should you have any questions, please call (203) 613-1033 or (203) 622-0004 or email at: coachnicolae@msn.com
Athlete's Name:_____________________________________ Age:___ Birth Date: ______________
Parent Name: ______________________________ Cell Phone ____________________
Emergency contact:__________________________ Phone: ______________ Cell Phone_______________
Address:_________________________________________________
Street
__________________________________ ______ ____________
City
State Zip
Phone: ____________________ E-mail: _________________________________
Dates:
Saturday session – September 10, 17, 24. October 1, 8, 15, 22, 29.
Circle the class that you would like to attend:
|
|
Saturday |
|
|
9:00-9:45 3-4 yr. old class |
|
|
9:50-10:35 4-5 yr. old class |
|
|
10:40-11:25 3-4 yr. old class |
|
|
11:30-12:30 5-6 yr. old class |
|
|
12:30-1:30 7-11 yr. old class |
Please make checks
payable to Nicolae Piperea
(8 weeks) [ ] $250
(45') [ ] $275 (1 hour)
A family with 3 or more kids will benefit of the 10% discount for all the
children.
HEALTH
CERTIFICATE : My daughter/son is in
good health and has my full permission to participate in the Soccer Clinic.
She/He has no previous sickness, illness, or disease or bodily injury that is
adverse to participation in the Soccer Clinic. It is understood that the
medical insurance policy insures against loss resulting directly from
participation in the Soccer Camp not exceeding $2000 and after your own
insurance has been used.
Signature:___________________________