Men's Soccer Clinic Registration

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REGISTRATION FORM

Men's Soccer College Prospect Clinic

Tel 978-665-4693 • Fax 978-665-3710 • wthissen@fitchburgstate.edu

ZIP Code *

Email address *

Cell Phone Number *

Address 2

City *

Address 1 *

Last name *

State *

First name *

Home Phone *

Age *

DOB *

Athletic Information

High School *

Year of Graduation *

Club Team

Primary Position *

T-Shirt Size *

Medical Information

Insurance Company *

Policy Number *

Medications *

Allergies *

Emergency Contact

Name *

Phone Number 1 *

Phone Number 2

Payment Information:

Payment in full must be received within 7 days after registration and made payable to: Fitchburg State Athletics Dept., Memo: MSOC Clinic

Mail payment with completed waiver form to: Fitchburg State University, Athletics Department, Men’s Soccer, 160 Pearl Street, Fitchburg, MA 01420

Important: Each participant must complete the waiver and emergency authorization form and mail it with the payment.

Questions: Contact Head Coach Werner Thissen at (508) 246.9437 or email at wthissen@fitchburgstate.edu

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