FC Academy PlusOne Soccer Program: Application Form
PlusOne Contact Information
Mother’s Name: _____________________________
Address: ____________________________________
Home Phone: ________________________________
Work/Cell Phone: ____________________________
Father’s Name: ______________________________
Address (if different): __________________________
Home Phone (if different): ______________________
Work/Cell Phone: _____________________________
Additional Emergency Contact Name:
____________________________________________
Relation to Student: ___________________________
Emergency Contact Phone: _____________________
Please Read and Sign Below:
I hereby authorize FC Academy (FCA) to seek medical treatment in the event of an emergency
and circumstances not allow timely contact of a parent or emergency contact. As a condition of
my child’s voluntary participation in the FCA PlusOne Soccer Program, I agree to waive any claim
and to hold FCA harmless for any injuries to my child, provided FCA and/or its agents have acted
with reasonable care to provide safe conditions and adequate supervision. I hereby grant FCA
permission to allow my child’s photograph to be used in club publications and marketing materials.
Signature: ___________________________________
Email Address: (for confirmations)
Complete form and mail check for $180.00 made out to
FC Academy, 315 10th Avenue, N. Suite 108, Nashville, TN 37203
Please list any physical or medical conditions/limitations your child(ren) may have that we need to be
aware of to better care for them:
______________________________________________________________________________
Player Information
Name: ______________________________________
Age: _________ Grade in spring 2010: ______________
T-Shirt Size (YM, YL, YXL, S M L XL ): Circle size.
Shorts- ( YM, YL, YXL, S, M, L, XL): Circle size.
Spring Sessions: TBA
4:30 – 6pm @ University School of Nashville, River Campus. Campus is located at 2100 County Hospital Road, Nashville.
