SYA E COURSE ON 722-24/11 - REGISTRATION FORM

July 22 - 6:30pm- 9:30pm Classroom / Theory - Location: Liberty MS, 6801 Union Mill Rd, Clifton, VA room B126

July 23 - 8:30am - 5:15pm FIELD WORK - Location: SYA Sports Park: 6626 Bull Run Post Office Rd, Centreville, VA

July 24 - 8:30am - 5:15 FIELD WORK - Location: SYA Sports Park: 6626 Bull Run Post Office Rd, Centreville, VA,

Question Title

* APPLICANT'S ADDRESS

Name: *

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

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* APPLICANT'S CONTACT INFORMATION

PHONE

E-MAIL

DATE OF BIRTH

OCCUPATION

LEAGUE/CLUB AFFILIATION

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* APPLICANT'S EXPERIENCE

PLAYING EXPERIENCE

COACHING EXPERIENCE

NOW COACHING: AGE

NOW COACHING: GENDER

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* METHOD OF PAYMENT

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* 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.

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* EMERGENCY CONTACT

NAME

PHONE

Note: The VYSA Accident Medical and Liability Insurance does not cover candidates participating in
VCE activities.

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* INSTRUCTOR'S EVALUATION

PASSED

FAILED

INSTRUCTOR'S NAME

INSTRUCTOR'S SIGNATURE