Registration forms
Italian Olympic Committee Sanctioned Soccer Training After School Program - Friends Meeting School - Ijamsville, MD September 19 to December 15, 2016 Sessions: Select one: ❑ Mondays: 3:30-5:00pm, Coed - Ages 5-9 (indoors) ❑ Tuesdays: 3:30-4:30pm, Coed - Grades 5-12 (outdoors) Instructor: Fabio Diletti AC Cugini President and Founder Fabio Diletti is an International Representative for the Italian National Olympic Committee (USA and Canada), Technical Director of the Roma Academy Maryland, and talent scout for various Italian professional men's and women's clubs. A native Italian, Fabio is a professional trainer and talent scout who played goalkeeper for Italian professional club Ascoli Calcio - founded in 1898. Fabio possesses a UEFA license and receives training twice a year in Italy through Italian National Olympic Committee (CONI Servizi) and Italian Soccer Federation coach training programs. Fabio has been coaching and training American players in the United States and Italy for over 20 years. Coach Dilettii is also the former Head Coach of the Women's Premier Soccer League (WPSL) team, ACF Torino USA as well as former Head Coach of Langley High School (VA) Girls JV Soccer team and South Lakes High School (VA)( Girls JV Soccer team and Goalkeeper Coach for both schools' Varsity and JV Girls teams. Registration questions? Contact: [email protected]; 866.792.9433 No child may participate without first submitting the registration below. Registration forms will be accepted by Mara Nicastro, Friends Meeting School: [email protected], 301.798.0288 Friends Meeting School students (only) may also email registrations to: [email protected] Complete sections 1 & 2, sign /date registration. Make check payable to “AC Cugini” (non Friends Meeting School students only) SECTION 1— Program Fee: (Select one) ❑ Friends Meeting School Student - FREE
❑ Non Student - $100
SECTION 2— Player Data and Parental Acknowledgement / Waiver & Release (must be signed by parent or guardian) First & last name_________________________________________ Date of birth_____________________________________________ Street address___________________________________________ City___________________________ State______ Zip __________ Home telephone_________________________________________ Email addresses __________________________________________ ______________________________________________________ Mother’s name____________________________________________ Mother’s cell #___________________________________________ Father’s name___________________________________________ Father’s cell # ____________________________________________ Emergency contact & telephone #___________________________ ______________________________________________________ Doctor’s name & telephone #_______________________________ ______________________________________________________ Known medical issues, allergies_____________________________ ______________________________________________________ Insurance company______________________________________ Insured ID# ____________________________________________ Policy holder’s name _____________________________________
As parent/legal guardian of player named on this registration, I certify that he/she 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/RES Roma USA/Brescia Calcio including but not limited to practices, games, tournaments, camps, clinics, and any other activity associated with Cugini Soccer/AC Cugini/RES Roma USA during the period covered by this registration. I assume all risks and hazards incidental to the conduct of soccerrelated activities including transportation to and from all Cugini Soccer/AC Cugini/RES Roma USA/Brescia Calcio-related activities. I also understand and agree that if my child leaves the training program, at any time after registration is submitted, there are no refunds. I further hereby release, indemnify, and agree to hold harmless Cugini Soccer/AC Cugini/RES Roma USA/Brescia 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/RES Roma USA members. 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 ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND ACCEPT THE ABOVE WAIVER AND RELEASE. I UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING AND SIGN VOLUNTARILY.
Parent/Legal Guardian Name (Printed):_______________________________ Parent Signature: _________________________ Date: _________
P.O. Box 165, Great Falls VA 22066 [email protected] • 866.792.9433 www.cuginisocccer.com
ABOUT AC CUGINI AC Cugini, founded in 2000 and based near Washington, DC, is an official Italian scuola calcio (soccer academy) sanctioned by the Italian National Olympic Committee - Comitato Olimpico Nazionale Italiano Servizi (CONI Servizi) and the Italian Soccer Federation - Federazione Italiana Giuoco Calcio (FIGC). AC Cugini is a member of US Club Soccer, US Youth Soccer, Virginia Youth Soccer Association, Maryland State Youth Soccer Association, Eastern Development Program League (EDP), National Capital Soccer League (NCSL), Washington Area Girls Soccer League (WAGS), Old Dominion Soccer League (ODSL). In 2013, AC Cugini affiliated with professional Italian women's club, RES Roma Calcio Femminile and professional Italian men's club Brescia Calcio. As the first and only official Italian academy in North America sanctioned by CONI Servizi and FIGC, AC Cugini clearly offers a unique and exceptional training environment for American players. Our goal is to develop players over the long term and nurture passion for the game, in keeping with the long tradition and history of success of the Italian academy program model. AC Cugini chooses coaches and trainers who all follow the same Italian player development methodology. Because of AC Cugini's long history of working with soccer organizations in Italy and our staff's ability to communicate fluently in Italian, we have developed invaluable relationships with many high-level contacts in Italy, which allow us to create one-of-a-kind programs for American youth players and coaches. Our focus, rather, is to create a unique experience where American youth play against Italian teams or train with Italian professional clubs or CONI Servizi staff. This also allows our participants the chance to be reviewed closely by talent scouts from professional Italian clubs with the necessary translation assistance available to support any player selected by an Italian club. For more information on AC Cugini or current programming, vsit the AC Cugini website: www.cuginisoccer.com or Facebook page: www.facebook.com/ACCugini or contact AC Cugini Executive Director Lisa Cherubini: [email protected], 866.792.9433
❑ Non Student - $100
SECTION 2— Player Data and Parental Acknowledgement / Waiver & Release (must be signed by parent or guardian) First & last name_________________________________________ Date of birth_____________________________________________ Street address___________________________________________ City___________________________ State______ Zip __________ Home telephone_________________________________________ Email addresses __________________________________________ ______________________________________________________ Mother’s name____________________________________________ Mother’s cell #___________________________________________ Father’s name___________________________________________ Father’s cell # ____________________________________________ Emergency contact & telephone #___________________________ ______________________________________________________ Doctor’s name & telephone #_______________________________ ______________________________________________________ Known medical issues, allergies_____________________________ ______________________________________________________ Insurance company______________________________________ Insured ID# ____________________________________________ Policy holder’s name _____________________________________
As parent/legal guardian of player named on this registration, I certify that he/she 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/RES Roma USA/Brescia Calcio including but not limited to practices, games, tournaments, camps, clinics, and any other activity associated with Cugini Soccer/AC Cugini/RES Roma USA during the period covered by this registration. I assume all risks and hazards incidental to the conduct of soccerrelated activities including transportation to and from all Cugini Soccer/AC Cugini/RES Roma USA/Brescia Calcio-related activities. I also understand and agree that if my child leaves the training program, at any time after registration is submitted, there are no refunds. I further hereby release, indemnify, and agree to hold harmless Cugini Soccer/AC Cugini/RES Roma USA/Brescia 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/RES Roma USA members. 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 ACKNOWLEDGE THAT I HAVE READ, UNDERSTAND, AND ACCEPT THE ABOVE WAIVER AND RELEASE. I UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I GIVE UP SUBSTANTIAL RIGHTS BY SIGNING AND SIGN VOLUNTARILY.
Parent/Legal Guardian Name (Printed):_______________________________ Parent Signature: _________________________ Date: _________
P.O. Box 165, Great Falls VA 22066 [email protected] • 866.792.9433 www.cuginisocccer.com
ABOUT AC CUGINI AC Cugini, founded in 2000 and based near Washington, DC, is an official Italian scuola calcio (soccer academy) sanctioned by the Italian National Olympic Committee - Comitato Olimpico Nazionale Italiano Servizi (CONI Servizi) and the Italian Soccer Federation - Federazione Italiana Giuoco Calcio (FIGC). AC Cugini is a member of US Club Soccer, US Youth Soccer, Virginia Youth Soccer Association, Maryland State Youth Soccer Association, Eastern Development Program League (EDP), National Capital Soccer League (NCSL), Washington Area Girls Soccer League (WAGS), Old Dominion Soccer League (ODSL). In 2013, AC Cugini affiliated with professional Italian women's club, RES Roma Calcio Femminile and professional Italian men's club Brescia Calcio. As the first and only official Italian academy in North America sanctioned by CONI Servizi and FIGC, AC Cugini clearly offers a unique and exceptional training environment for American players. Our goal is to develop players over the long term and nurture passion for the game, in keeping with the long tradition and history of success of the Italian academy program model. AC Cugini chooses coaches and trainers who all follow the same Italian player development methodology. Because of AC Cugini's long history of working with soccer organizations in Italy and our staff's ability to communicate fluently in Italian, we have developed invaluable relationships with many high-level contacts in Italy, which allow us to create one-of-a-kind programs for American youth players and coaches. Our focus, rather, is to create a unique experience where American youth play against Italian teams or train with Italian professional clubs or CONI Servizi staff. This also allows our participants the chance to be reviewed closely by talent scouts from professional Italian clubs with the necessary translation assistance available to support any player selected by an Italian club. For more information on AC Cugini or current programming, vsit the AC Cugini website: www.cuginisoccer.com or Facebook page: www.facebook.com/ACCugini or contact AC Cugini Executive Director Lisa Cherubini: [email protected], 866.792.9433
