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2015 EduKick Registration Form – Page 1
INSTRUCTIONS: To register online, visit our website at www.edukick.com: Or please return this 3-page registration form
(completed fully & signed by Parent/Guardian & Player) with your deposit payment and $200 USD NON-REFUNDABLE registration fee.
You can mail, email or fax this form to EduKick. Space is limited in each EduKick course. It is recommended that you register now.
You will receive additional program information from EduKick, Inc. via email upon receiving this completed 2015 Registration Form.
PARENT INFORMATION (Please Print )
Parent / Guardian Full Name: ____________________________________________________________________________________
Mailing Address: ______________________________________________________________________________________________
City, State or Province: _________________________________________________________________________________________
Postal Code, Country: __________________________________________________________________________________________
Home Telephone: (
)_____________________Cell: (
)_______________________Work: (
) _______________________
Email (mandatory):____________________________________________________________________________________________
Emergency Contact Name: ______________________________________________Relationship: _____________________________
Emergency Contact Telephone: (
)_______________________________________Email: ________________________________
Please briefly explain what you hope your child will accomplish with EduKick: ____________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
How did you hear about EduKick? □ Google (Internet) Search □ You Tube Video □ A friend □ Other ________________________
PLAYER INFORMATION
Full Name (as it appears on your current passport): __________________________________________________________________
Mailing Address: _____________________________________________________________________________________________
Passport # & Issuing Country: ______________________________________________________ Exp. Date : _________________
E-mail:_______________________________________ Date of Birth: ____ /____
mm
dd
/____ Age:______ Gender: □ Male □ Female
yyyy
Soccer Position(s): □ Striker □ Mid-fielder □ Defender □ Goalkeeper -- Year Played Soccer: □<4 yrs
Adult T-Shirt Size: □ Small
□ Medium
□ Large □ X-Large -- Foreign Language Level: □ Beginner
□5-6 yrs □7-8 yrs □9 yrs+
□ Intermediate □ Advanced
Please indicate any medical condition (i.e. Allergies, Asthma, Illnesses, Previous Injuries, etc.) or any “Special Instructions” here:
__________________________________________________________________________________________
____________________________________________________________________________________________________________
Roommate Request: □No □ Yes - If yes, name of friend: ______________________________________________________________
Favorite player, interests & hobbies:______________________________________________________________________________
____________________________________________________________________________________________________________
Briefly explain what you hope to accomplish with EduKick: ____________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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2015 EduKick Registration Form – Page 2
2015/16 PROGRAM SELECTION: Please check the program(s) that you are registering for (AIRFARE NOT INCLUDED):
□ Santa Barbara, CA, USA (August - June) - $46,990 USD *EduKick USA – High School Soccer & Education Academy (Internationals)
□ Santa Barbara, CA, USA (August - June) - $34,990 USD *EduKick USA – High School Soccer & Education Academy (USA)
□ Hennef, Germany (August - June) - $39,990 USD *EduKick Germany – High School (11 Month) Football & Education Academy
□ Hennef, Germany (March - June) - $15,990 USD *EduKick Germany – Semester (Three Month) Football & German Language Study
□ Hennef, Germany (March - June) - $5,499 USD *EduKick Germany – “Monthly” (28 day) Football & German Language Study
□ Puerto Vallarta, Mexico (throughout year) - $1,499 USD *EduKick Mexico Weekly Individual Soccer/Spanish Course
□ Puerto Vallarta, Mexico (January - May) - $17,990 USD *EduKick Mexico ½ Year Spanish & Futbol/Soccer
□ Puerto Vallarta, Mexico (September-May) - $24,990 USD *EduKick Mexico Academic Year Spanish & Futbol/Soccer
□ Manchester, England (July 5 - 26) - $4,999 USD *EduKick Manchester “Residential” Summer English/Football Camp (11-17 years)
□ Manchester, England (July 26 – August 30) - $6,999 USD *EduKick Manchester “Academy” Pre-Season Football Camp (Boy only 14+)
□ Manchester, England (September-June) - $40,990 USD *EduKick Manchester Academic Year Football Studies
□ Manchester, England (January - June) - $29,990 USD *EduKick Manchester ½ Year Football Studies
□ Manchester, England (August, October, February or April) - $6,999 USD *EduKick Manchester 6 week Football (Soccer) Trial Program
□ Cannes, France (August - May) - $43,990 USD *Academic Year HIFA Academy – Boys or Girls
□ Cannes, France (January - May) - $29,990 USD *1/2 Academic Year HIFA Academy – Boys or Girls
□ Belo Horizonte, Brazil (throughout the year) - $1,599 USD *Weekly Individual Training Camp – Cruzeiro Esporte Clube
□ Belo Horizonte, Brazil (throughout the year) - $4,199 USD *Monthly Individual Soccer Training - Cruzeiro Esporte Clube
□ Belo Horizonte, Brazil (May - October) - $21,990 USD *1/2 Year High School/Portuguese - Cruzeiro Esporte Clube School
□ Belo Horizonte, Brazil (February - October) - $28,990 USD *Academic Year “Portuguese Study” - Cruzeiro Esporte Clube School
□ Madrid, Spain (June 14 – July 12) - $4,799 USD *4 week Spanish & Soccer Training Camp (individual weeks available upon request)
□ Madrid, Spain (August - June) - $6,999 USD *6 WEEK Module Course - Taster Program for Academic Year Soccer Boarding School
□ Madrid, Spain (August 18 – June 19) – $47,990 USD *Academic Year Soccer Boarding “Private Middle/High School” - (13-16 years)
□ Madrid, Spain (August 18 – June 7) – $43,990 USD *Academic Year Soccer Boarding School “Spanish Language Study” – (16+ years)
□ Madrid, Spain (January 5 – June 7) – $27,990 USD *1/2-Year Soccer Boarding School “Spanish Language Study”
□ Perugia, Italy (throughout the year) – $5,499 USD *Monthly” Custom Individual Soccer Option - Italian Soccer School
□ Perugia, Italy (Spring, Winter or Fall) – $12,990 USD *(3 Month) “Italian Language Study” & Football Training Academy
□ Perugia, Italy (July 4 - 18) – $2,999 USD Italian Language & Football Training Camp
TUITION PAYMENT SCHEDULE: (To register online, visit our website at www.edukick.com)
Registration Fee: $200 USD – NON-REFUNDABLE – Due with Payment #1 at Registration for ALL EDUKICK PROGRAMS
Payment #1: 15% Deposit Payment DUE with Registration (Due now)
Payment #2: 60% of remaining balance due sixty (60) days prior to departure (or July 1st for Boarding School Academy Programs)
Payment #3: Final payment of remaining balance due thirty (30) days prior to departure (or September 1st for Boarding School Academy Programs)
REGISTRATION FEE & DEPOSIT PAYMENT #1:
Please choose payment method for Deposit Payment #1 & Registration Fee:
□ CHECK: Enclosed is my deposit check or money order made payable to EduKick, Inc. in the amount of _________________USD.
□ CREDIT CARD: Please charge my: □ VISA □ MasterCard □ Discovery □ American Express --- *Note: 3% admin fee applies for all credit card charges
□ WIRE TRANSFER: I will wire transfer the deposit payment to: Contact EduKick, Inc. for our bank account information.
Credit Card Account Number: ____________________________________________________________ Exp. Date: ____/____
mm yy
Cardholder Full Name: _________________________________________________________________________________________
Mailing Address (associated with this credit card): ___________________________________________________________________
BALANCE PAYMENTS #2 & #3: Please choose payment method for your two additional payments:
□ CHECK: I will send personal checks or money orders
□ CREDIT CARD: I authorize you to charge my □ VISA □ MasterCard □ Discovery □ American Express on the 2015/16 due dates
□ BANK WIRE TRANSFER: I will wire transfer the final two (2) payments to the EduKick corporate bank account
PAYMENT IN FULL: (All summer courses must be paid in full if registering after May 1st):
□ Please find my enclosed tuition payment in full – Payment Method: □ CHECK: □ CREDIT CARD: □ BANK WIRE TRANSFER
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2015 EduKick Registration Form – Page 3
RECOGNITION AND ASSUMPTION OF RISK AGREEMENT& PHYSICIAN RELEASE
I, the undersigned parent/legal guardian of (player’s full name)_______________________________
authorize said child's full participation in EduKick 2015 and related language/soccer school/camp
activities (including EduKick 2015 Soccer Boarding Schools, “Monthly” Training Programs, Custom
“Team Tours” and summer camps). It is my understanding that participation in the activities that
make up EduKick 2015 courses is not without some inherent risk of injury. As such, in consideration
of my child's participation in the selected EduKick 2015 Program, I hereby release, waive, discharge,
and covenant not to sue the EduKick, Inc., EduSport Enterprises, Inc., or its servants, agents or
employees from any and all liability, claims, demands, action, and causes of action whatsoever arising
out of or related to any loss, damage, or injury, including death, that may be sustained by my child,
whether caused by the negligence of the releases, or otherwise while participating in such activity, or
while in, or upon the premises where the program activity is being conducted.
I also give my permission for any emergency medical care or treatment by a physician, surgeon,
hospital, or medical care facility that may be required, including transportation, and accept
responsibility for the cost. I also understand that a medical insurance policy carried by EduKick, Inc.,
if any, will provide only minimum coverage and that I should make sure my child is covered with
family insurance in the event of a serious accident. I also understand and agree that if my child (dren)
violates any of the academic year boarding school or summer camp rules or regulations (included in
the pre-departure packet) that he/she may be sent home early at our own expense.
Print Player's Name: _______________________________________________________________
Print Parent/Guardian Name: ________________________________________________________
Personal Health Insurance Company: __________________________________________________
Insurance Policy Number: ___________________________________________________________
Parent/Guardian Signature: ________________________ Date:___________________________
I, ___________________________________, (player’s full name) have read and agree to follow all
instructions and procedures as outlined on the EduKick “Policy” webpage in order to maintain a
maximum level of safety and security while abroad with EduKick, Inc. I understand that if I violate
any of the academy boarding school or summer camp rules (also to be included in the pre-departure
packet); EduKick, Inc. reserves the right to send me home early at my own or my parent’s expense.
Player's Signature: _______________________________ Date: ____________________________
Nationality & Passport #: ____________________________________________ Exp. Date: ____/____/____/
Fax to: 1- 905 – 469-5971 --- REF.#___________ (if referred by an Agent)
Mail to: 2193 Glengrove Crescent - Oakville, Ontario
L6M 3X5 Canada
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