Winter Indoor Skills Training + Futsal with Instructor from Italian

Winter Indoor Skills Training + Futsal with Instructor from Italian National Olympic Committee December 6, 2015 -­‐ March 27, 2016 Sundays @ YMCA Reston Coed – Ages 7–14 Fee: (17 sessions): $180 (early registration fee); $205 (late registration fee after 11/15/15; subject to availability)
Sunday Sessions: ❐ Ages 7-8: 11:30am-1:00pm ❐ Ages 9-11: 10:00am-11:30am ❐ Ages 12-14: 8:30am -10:00am
Instructor: Fabio Diletti: 703.477.5957; [email protected]
Fabio Diletti is President & Founder of AC Cugini, Technical Director of RES Roma USA Girls Academy Program, international representative for the
Italian National Olympic Committee - Comitato Olimpico Nazionale Italiano Servizi (CONI Servizi), and former Head Coach of Womens Premier Soccer
League (WPSL) team ACF Torino USA. A native of Ascoli Piceno, Italy, Fabio played as a goalkeeper for professional Italian club Ascoli Calcio. He
possesses a UEFA license and receives ongoing training twice a year in Italy through Italian National Olympic Committee and Italian Soccer Federation
coach training programs. With over 20 years experience training and coaching youth players in the United States and Italy, Fabio also serves as a
talent scout for numerous Italian professional clubs.
About AC Cugini: Based near Washington, DC, AC Cugini is an official Italian scuola calcio (soccer academy) sanctioned by CONI Servizi and the
Italian Soccer Federation - Federazione Italiana Giuoco Calcio (FIGC). AC Cugini is a member of Virginia Youth Soccer Association, US Youth Soccer, the
National Capital Soccer League, the Old Dominion Soccer League, and the Washington Area Girls Soccer League. In 2013, AC Cugini affiliated with
professional Italian women’s club, RES Roma Calcio Femminile, the women's side of Italian premier league AS Roma, as well as with professional Italian
men’s club Brescia Calcio. As the first and only official Italian scuola calcio in North America sanctioned by CONI Servizi and FIGC, AC Cugini clearly offers
a unique and exceptional training environment for American players in the Unites States and Italy (where players have the opportunity for tournament play,
review by professional scouts, and training at the Italian Olympic Athletes Training Center in Rome). More info: www.cuginisoccer.com
Cut here and mail registration below with payment.
AC Cugini Winter Indoor Training + Futsal: 12/6/15 – 3/27/16
Player’s first name________________________ Last name_____________________________________ Date of birth ______________________
Street address____________________________________________________ City_______________________ Zipcode ____________________
Mother’s name____________________________________________ Father’s name __________________________________________________
Home telephone #___________________________ Mother cell#__________________________ Father cell#______________________________
Email address _________________________________________ Emergency contact name & telephone #_________________________________
Known medical issues, allergies________________________________________________ Doctor’s telephone #____________________________
Is player covered by insurance? ❐ Yes ❐ No
Insurance company _________________________ Policy# ____________________ Policy holder’s name _________________________
❐ Select One Age Group:
❐ Ages 7-8: 11:30am-1:00pm
❐ Ages 9-11: 10:00am-11:30am
❐ Ages 12-14: 8:30am-10:00am ❐ Standard fee: $180 (by 11/15/15) ❐ Late registraation fee: $205 (after 11/15/15) ❐ AMOUNT PAID: $_______ ❐ Medical Release & Liability Waiver (must be signed and dated by player’s parent or guardian to finalize registration)
As parent/guardian of player named on this registration, I certify that he/she is covered my medical insurance and is in excellent health and has no physical, mental, or
emotional problems which are likely to prevent participation in strenuous activities. I hereby give my approval for above player to participate in all activities of Cugini
Soccer, AC Cugini Scuola Calcio, including but not limited to practices, games, tournaments, camps, clinics, and any other activity associated with Cugini Soccer Club,
AC Cugini Scuola Calcio. I assume all risks and hazards incidental to the conduct of soccer-related activities including transportation to and from all Cugini Soccer/AC
Cugini-related activities. I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry and certify that above
player is covered by medical insurance. I further hereby release, indemnify and agree to hold harmless Cugini Soccer, AC Cugini Scuola Calcio, and its officers, directors,
agents, sponsors, volunteers, and other staff from any claim, suit, demand, or action arising out of injury to above player or my family’s involvement as Cugini Soccer/ AC
Cugini Scuola Calcio members. I acknowledge that I have read, understand, and accept all published AC Cugini Soccer policies (including the Cugini Code of Conduct)
and this waiver and release. I also understand there are no refunds once payment has been submitted. I understand this is a release of liability and I give up
substantial rights by signing it and sign it voluntarily.
Parent/Guardian name: (print) ___________________________ Parent/Guardian signature ______________________________ Date ________
Mail Registration and Payment to: AC Cugini, P.O. Box 165, Great Falls, VA 22066
Questions? Call 866.792.9433 • email: [email protected]
www.cuginisoccer.com