Winter Home School Registration
LAST NAME:_____________________________FIRST NAME:_________________________
o Male o Female Birthdate_______________
Address __________________________________________________________________________________
City/State/Zip______________________________________________________________________________
Ph. ( ________ )__________________ Email Address___________________________________________
Parent/Guardian Name___________________________________
Medical Insurance Co.______________________________ Policy No.:_____________________________
IMPORTANT NOTE: Enrollment is limited. Full and final payment is due at the time of registration.
Parental release: This is to certify that my son/daughter has permission to participate in any and all
activities. I assume all risks and hazards incidental to such participation, and I do hereby agree
to hold harmless the staff of the AllStar Sports Arena and O’Brien Soccer Training, LLC from any and
all claims arising out of any injury to my child. Furthermore, this verifies that the player is up to date
with his/her immunizations and is able to participate in all activities. In the event of injury my
permission is granted for treatment as required at the nearest medical treatment facility.
Medical problems (allergies, seizures, etc.):___________________________________________________
Guardian's Signature:______________________________________________________________________
In an emergency, if no answer at above #, please call:
Name_______________________________________ Ph. ( _________ ) ___________________________
Choose One:
Fall Session - 12 weeks (Dec 6 - Feb. 28, no soccer on Dec. 27) $75
Fall Session - 4 week payment $25
SEND WITH FULL PAYMENT TO:
All Star Sports Arena Soccer / 1906 Cambridge St / Springdale, AR 72762
For more information call Nancy O'Brien at 445-7100 or email: allstarsoccer@cox.net.
