SYA D COURSE ON 8/20-22/2010 and 8/27-29/2010 - REGISTRATION FORM

In order to take the D Course, you MUST SUBMIT A COPY of your E certificate or an approved waiver with this form. Please mail it with your payment to SYA office at:
3819 Plaza Drive, Attn: Beth Bogemann / D Course, Fairfax, VA 22030 or fax 703-539-8633.

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* APPLICANT'S ADDRESS

Name: *

Company:

Address: *

Address 2:

City/Town: *

State: *

ZIP: *

Country: *

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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: TEAM AGE

NOW COACHING: TEAM 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