Canadian National Soccer Academy - Club America

New Student Application
General Information
Name: First
Middle
Last
Program
Semester interested in enrolling for
Birth Date M/d/yyyy
Place of Birth
Destination (Leave blank if not applicable.)
Sex Male Female
Country
Nationality
Passport Number (Leave blank if not applicable.)
Visa Type (Leave blank if not applicable.)
Visa Expiry Date mm/dd/yyyy (Leave blank if not applicable.)
Residency Status
Address: Street
City
State/Province
Zip/Postcode
Country
Contact Phone: Home
Cell
Email

Guardian Contact Information
Guardian Name
Relationship
Address
Street
City
State/Province
Zip/Postcode
Country
Phone
Email

Emergency Contact Information
Contact Name
Relationship
Contact Phone
Home
Work
Cell
E-mail
Contact Name 2
Relationship
Home Phone
Work Phone
Cell Phone
E-mail
Doctor’s Name
Phone
Alberta Health Care #

Disability Information
Disability Yes
No 		Description
Learning Difficulties Yes
No 		Description

Additional Information
Do you have any allergies? :YesNo
If yes, please list:
Are you taking any medications? :YesNo
If yes, please list:
Do you have any special needs? :YesNo
If yes, please list:
Do you have any conditions that will affect your participation in the program?:YesNo
If yes, please list:


I/We the undersigned hereby certify that I/we am/are the parent(s) or legal guardian(s) of the participant. I/We hereby give permission for the staff of the Academy to seek appropriate medical attention for the participant and for the medical attention to be given and for the participant to receive medical attention in the event of an accident, injury or illness. I/We will be responsible for any and all costs of medical attention and treatment. I/We, the undersigned for ourselves, our heirs, executors and administrators waive, release and forever discharge Pro Canadian Soccer Group Inc. and it’s staff, officers, agents, employees, representatives, successors and affiliates, and assigns of and from all rights and claims for damages, injury or loss to persons or property which may be sustained or occur during participation in Academy activities or while at the Academy, whether or not damages, injury or loss is due to negligence. I/We hereby acknowledge that our child is physically fit and mentally capable of participating in the soccer Academy‘s activities.