Texas Lutheran University

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RECEIPT

TLU Men's Soccer College ID Clinic 2020

Sunday, February 16th, 2020 10:00 a.m. - 4:00 p.m.
Gustafson Soccer Field on Texas Lutheran University's campus

Eddie Salazar - Camp Director and Men's Soccer Coach
Walter Pinon - Men's Soccer Assistant Coach

Join us on Sunday, February 16th at 10:00AM for our College ID Clinic 2020. All participants should attend camp in the proper attire of a t-shirt, shorts, shin guards, and soccer socks (covering their shin guards). Soccer balls and water will be supplied.
TLU is not responsible for lost items or equipment.

Registrations

$75 Early Registration- on/before Feb. 2, 2020
$85 registration after Feb. 2, 2020

Qty

Description

Amount

Total

Participant(s)

$85.00

Total: $85.00

Participant Information

PRINTABLE WAIVER: Please CLICK HERE to print your Waiver and bring with you.

First Name: *

Last Name: *

Date of Birth: *

Phone: *

T-Shirt Size: *

Current College/
High School: *

Graduation Year: *

Academic Interest: *

Parent/Guardian: *

EMERGENCY CONTACT INFORMATION

Insurance: Parents/Guardians are responsible for providing proof of insurance.

Emergency Contact Name: *

Emergency Contact Phone: *

Emergency Email:

Physician’s Name: *

Policy ID Number: *

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone:

E-mail: *

A receipt will be e-mailed to this address.

Your Payment Information

Name on Card: *

Card Number: *

Security Code: *

Expiration Date: *

Name on Account: *

Routing Number: *

Account Number: *