Player Name: _________________________________________________

Address: ____________________________________________________

Telephone No. __________________________________________

Parent Name(s): ______________________________________________

Parent Address: ______________________________________________

We are able to pay $___________ towards the registration fee

Payment schedule requested______________________________________

Player is eligible for :

[ ] Reduced school breakfast/lunch
[ ] Free  school breakfast/lunch

Please provide us with any information which you wish to provide in support of the scholarship request:

___________________________________________________________

___________________________________________________________

___________________________________________________________

___________________________________________________________


Return to team coach or to:     Treasurer, Albany Soccer Club, Inc.
                                                 117 Orlando Avenue
                                                 Albany, New York  12203