Registration Form
 

All programs will be held at The Habitat for Soccer and Sports, Inc., Uxbridge, MA.
Please complete one form per participant.
*Checks can be made payable to "Composure Training".
 
 

Wednesdays 4:30 - 6:00pm
Session I: Jan 6, 13, 20, 27; Feb 3, 10
Session II: Feb 24; Mar 3, 10, 17, 24
 $145.00 per player - 6 weeks
$275.00 per player - 12 weeks
Premier Program
Tuesdays 4:30 - 6:00pm
Jan 26; Feb 2, 9, 23; Mar 2, 9, 16, 23		 $185.00 per player - 8 weeks
    Total Payment:

Name:
Age:
Address:
Home Phone:
Mobile Phone:
Email1:
    
Email2:
    
Shirt Size:
Adult Small Adult Medium Adult Large

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 
    Medical Release Form  
   

Composure Training Program
Player Medical Release Authorization Form

I/we the parents and/or guardian of hereby give my/our approval of his/her attendance and participation in all activities of the Composure Training Program. I understand that there is an inherent risk of injury due to the nature of the sport of soccer. He/she is in good health and able to participate in the physical activities involved with a demanding athletic training program. I/we assume all risks and hazards related to participation; including transportation to and from the program location.  I/we hereby waive, release indemnify and to hold harmless the Composure Training Program, its affiliates, program director, coaches, sponsors and hosts, from any claim resulting in athletic, dental, or bodily injury that may occur to my son/daughter while attending the Composure Training Program.  Also, it is my understanding that Composure Training does not carry medical insurance and that my medical insurance is expected to cover my child’s injuries. I authorize the Program Director to act on my behalf in any emergency requiring medical attention.

Medical Insurance Company
 
Policy Number
  

In case of emergency notify:
Name
Primary Phone
Mobile Phone
Relationship
List of any known allergies or medical conditions:

In accordance with Massachusetts General Law 105 CMR 430.000, please also provide signed copies of the following:
-Physical Exam Report having been conducted within the 24 months prior to the camp in which the player is enrolled.
-Immunization Record that includes MMR#1, Polio, Diptheria, Tetnus Toxoids and Pertussis (Dta/DTP/DT/Td) and Hepatitis B (for those participants born on or before 1/1/92).

Parent/Guardian Signature
 _____________________________________________________
Date
 ______________

 

  

 

 

 
   

Fill in completely, print, sign, and mail with payment to:
Composure Training - 13 Ashworth Drive - North Oxford, MA 01537