FUTURE STARS SPORTS ACADEMY APPLICATION
Name_____________________________________
Address____________________________________
City_________________State______Zip_________
Sport____________________________Session #__
Location ___________________________________
DOB __________ Age_____ Grade____ Sex _______
Phone______________________________________
Email Address________________________________
Emergency Contact Name: _____________________
Emergency Phone #:__________________________
Physician’s Name_____________________________
Phone # ____________________________________
I hereby request that my child be admitted to the Future Stars Academy and authorize the directors to act for me according to their best judgment in any emergencies requiring medical attention. Further, I hereby grant full permission for event organizers to record any and all of my participation in those events for photos, motion pictures, TV/radio recording, videotapes, and other media known or unknown and to use them no matter by whom taken, in any manner for publicity, promotions, advertising, trade or commercial purposes without any reimbursement of any kind due to me or the need to pay me any fee.
_____________________________________
Signature of Parent or Guardian
Date:____________________
TUITION PAYABLE WITH THIS APPLICATION
Make checks payable to: FSSA
Mail to: FSSA, 21 Captains Watch, Shelton, CT 06484
or fax to (203) 926-6922 with credit card #
Credit Cards Accepted: Visa, Master Card, American Express
Credit Card #___________________________Expiration Date _______________________
FOR OFFICE USE: _____IC ___SL
Amt Pd__________Amt Due__________
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