SYA E COURSE ON JULY 13-15, 2012 - REGISTRATION FORM

July 13 - 6:30pm- 9:30pm Classroom / Theory - Location: Liberty MS, 6801 Union Mill Rd, Clifton, VA room B126

July 14 - 8:30am - 5:15pm FIELD WORK - Location: SYA Sports Park: 6626 Bull Run Post Office Rd, Centreville, VA

July 15 - 8:30am - 5:15 FIELD WORK - Location: SYA Sports Park: 6626 Bull Run Post Office Rd, Centreville, VA,
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APPLICANT'S ADDRESS
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APPLICANT'S CONTACT INFORMATION
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APPLICANT'S EXPERIENCE
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METHOD OF PAYMENT
SIGNATURE
Please do not enter anything in the signature field as you will have to sign this form in person on the first day of the course.

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Being fully cognizant of the physical requirements of the Virginia Metro-DC Coaching Education Program, I am physically able to participate and hold the VCE, VYSA US Youth Soccer, and USSF, their coaching staff and each of their administrators, heirs, executors, successors, and assignors harmless for any injury or medical problem that might happen to me. I assume the risk of injury or medical problem, and I release and waive any claim that might be made by me or my heirs upon aforesaid.
EMERGENCY CONTACT
Note: The VYSA Accident Medical and Liability Insurance does not cover candidates participating in
VCE activities.
INSTRUCTOR'S EVALUATION
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