NHSA Coaching Course Application

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PERSONAL INFORMATION
First Name:			Last Name:
Date of Birth:			Gender	Select One ----- Male Female
	(Format: 01/02/33)

CONTACT INFORMATION
Street:			Email:
City:			Phone 1:
State:	(Example: NH)			(Format: 603-111-2222)
Zip:			Phone 2:
				(Format: 603-111-2222)

COURSE INFORMATION
NHSA Course	Select a Course ----- G Course (Derry, NH) - February 18, 2012 G Course (Pembroke, NH) - July 29, 2012 ----- E Course (Milford, NH) - August 19 & 26, 2012

NHSA AFFILIATION
Organization Name		OR	NonMember

ACTIVITY WAIVER
Please enroll the above individual. I, the participant, understand and hereby accept the condition that neither US SOCCER nor anyone associated with the US SOCCER License Program, or Host Organization will assume any responsibility for injury to me and medical or dental expenses incurred by me as a result of my participation in this program. I certify that I am in good health and able to participate in the physical activity of a vigorous program. I understand that my participation in the program's physical activities is voluntary. I hereby release and hold harmless US SOCCER and anyone associated with US SOCCER who is involved with any of this program's activities from liability for injuries occurred by me while participating in the program. In the event of an injury to me, I hereby grant my permission to US SOCCER's affiliated organizers to obtain medical care.
Waiver Accepted

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