Coaching Staff
| Brian Eaker: |
USSF National D Licensure |
| |
NSCAA Regional Goalkeeper |
| Javier
Sanchez: |
USSF D Licensure |
| |
NSCAA Regional Goalkeeper |
| Chris Ellis: |
USSF D Licensure |
| |
NSCAA Regional Goalkeeper |
| |
NSCAA State Diploma |
| |
NFHS Diploma |
| Ron Riggins |
NSCAA Regional Goalkeeper |
| Other coaching staff TBA |
|
Player Information
Name:_____________________________
Address:____________________________
City/St:____________________________
Zip:_______________________________
Age:_______________________________
Phone:_____________________________
Email:_____________________________
Shirt Size: YS YM YL S M L
XL
Club:______________________________
Emergency Contact Information
Name:_____________________________
Phone:_____________________________
Relationship:________________________
If you have any questions, please contact:
Javier Sanchez
keljav8@att.net
Chris Ellis
cjell12@hotmail.com
Brian Eaker
4eakers@mchsi.com
Entry deadline to guarantee t-shirt: June 1
Registration will be taken the day of the
camp
www.molinesoccerclub.com
www.molineunited.com
| |
Waiver (must be signed)
In consideration of the acceptance of my
son/daughter entry, I for myself, my
executors, administrators, and assigners, do
hereby release and discharge, Moline United,
City of Moline, Moline Soccer Club, any
sponsors or volunteers, for all claims and
damages, demands, actions whatsoever in any
manner arising from participation in the Big
Saves Goalkeeping Camp. I attest and verify
that I have full knowledge of the risks
involved in this event, and that my
son/daughter is physically fit, and
sufficiently trained to participate in this
event.
|
| |
**Players should bring a water bottle, shin
guards, gloves, and a ball. Also, bring
clothing appropriate for the weather
conditions.
SIGNATURE (parent or guardian if under 18)
______________________________________
DATE
__________________________________________
PLAYER NAME (please print)
_________________________________
Mail completed forms and check to:
Chris Ellis
1815 46th St
Moline, IL 61265
Make checks payable to Chris Ellis in the
amount of $49
Sent from my Verizon Wireless BlackBerry
