New or Returning Client *

First Name *

Last Name *

Date of birth *

Phone *

Email *

Address

Street Address *

City

Province

Country

Postal code

Parent/Guardian Name *

Parent/Guardian Phone # *

Parent/Guardian Email *

Male or Female? *

Male

Female

How many years of experience do you have? *

What team/club do you play for? *

What are your goals? What can Football Lab help you accomplish? *

What are your strengths? *

What are your weaknesses? What do you feel like you need to work on? *

Emergency Contact Name *

Emergency Contact Phone # *

Emergency Contact Relation To Player *

Do you take any medications? *

Payment

Please note that 5%GST price is reflected below

$250.00 + 5% GST = $262.50

Camp Selection *

Payment Method *

Credit Card Payment *

CA$ 262.5

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