Metro East Middle School Clinic Registration
First Name:
Last Name:
Phone:
E-mail:
Team/School
Grade (Fall 2009):
Address:
City:
State:
Zip:
Alt Phone:
Personal Information
Parental/Emergency Contact Information
Camp Waiver
I have read, understand, and abide by the following information. My child has my permission to participate in Elite Football Academy Activities. I certify that my child
has been examined by a licensed physician within the last 12 months, and is able to participate in all football related physical activities. I understand that my child may come in contact with other people and objects, and I hereby waive all rights to future claims related to such contact or injuries sustained as a result of such contact. I agree to assume any and all risks associated with my child’s participation in Training Sessions and release Elite Football Academy, its Owner, Staff, Participating Facilities,Host Schools and their respective School Districts from any and all liability related to injury or illness my child may sustain during training. I authorize Elite Football Academy, in the event of a medical emergency to transport and/or seek the necessary medical treatment for my child.
Football Information
Height:
Weight:
Shirt Size:
Father/Guardian Name:
Father/Guardian Phone Number:
Mother/Guardian Name:
Mother/Guardian Phone Number:
Emergency Contact Name:
Emergency Contact Phone Number:
Insurance Carrier:
Online Payment Instructions
Name Date
Once you click the Proceed button, you will be taken to the Camp Payment Page. Simply click "Add to Shopping Cart" and enter your payment information. You have the choice to pay with a Major Credit Card or a PayPal Account. Thank you and we look forward to working with you soon!
Football Training Experts Serving the Entire St. Louis Missouri Metro Area
Elite Football Academy LLC 17363 Edison Avenue Chesterfield, MO 63005 P:636.346.1371 F:314.787.9205
Date: Saturday January 23rd
Time: 8:30a-11:30a
Cost: $40.00
Includes EFA training shirt!
LOCATION: Vetta Sports - O'Fallon 590 Hartman Lane O'Fallon, IL 62269
