LIGHTHOUSE SOCCER CLUB
MAIL TO:
Visit us online at http://www.lighthousesoccer.org/
Last Name: ___________________________ First Name:
_______________________________
Address:
______________________________________________________________________
Social Security #:
_______________________________________________________________
(*needed for the EPYSA Risk management application,
You cannot be considered an applicant for coaching per EPYSA and
Home Phone #: (_____) _______-__________ Cell Phone #: (_____) _______-__________
City: _________________________________ State: _______ Zip:_____________________
Sex: M F Email:
___________________________________________________________
Medical Problems:
______________________________________________________________
Coaching Request Age
____ Male -
Female Level: Travel, Inhouse or TopSoccer
Playing Experience Yes
- No
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Coaching Experience Yes
- No
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Coaching Licenses and/or certifications Yes
- No
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SIGNATURE: ______________________________________________________________
DATE: ___________________