Private Lesson Request

Player Information

Player Name*

First NameLast Name

Player DOB*

Guardian/ Parent E-mail*

example@example.com

Guardian/Parent Cell *

Area CodePhone Number

Number of years playing*

	1	2	3	4	5	6	7	8	9	10

1 is Years, 10 is Years

What day/times do you request?

Ex. Mon/Wed 5pm

$70 for 1 hour private

$35 for 30 min private

Once you request is filled out, we will contact you to schedule Day/Times

Release of Liability

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to private lessons.
I give consent for the facility to secure any and all necessary emergency medical care.

Although the safety of all sport activities is the primary concern, soccer activities may cause injuries. I expressly assume the risk of injury, and/or illness arising from any cause, and agree to waive the right to pursue any claim against Memorial Soccer Academy and Houston Select coaches and the persons in charge.

I have read and agree to the above conditions*

YesNo

Signature*

After completing this form, please click Submit Form. You will receive a confirmation email. If you do not receive the email within a few minutes, please check your spam; otherwise, please contact us at info@memorialindoor.com