Name of QB:

Age: 
Grade and School:
Height/Weight: 

Name of Parent or Guardian:
Home Address:

Home/Contact Phone Number:

Please circle the Program of Interest:

Beginner QB
Emerging QB
Experienced QB  
On Field Evaluation

Please indicate time preference for lessons from the following:
(Please add preferred start and end dates - one lesson per week)

Monday - Friday    6:00 pm or after
Saturday              before noon
Sunday                Late afternoon (during Daylight Savings)

Note:  Lessons are scheduled based on coach's availability.  The
5 lessons can be scheduled over 5 weeks, or 2x a week if preferred.
All efforts will be made to schedule lessons at a time convenient for 
both the coach and the QB. Allow 1.5 hr for the first lesson which
includes an evaluation, one hour for the four remaining lessons.

Please circle the city where you would prefer to have lessons:

Charlotte, NC
Raleigh/Durham, NC
Atlanta, GA
Columbia, SC
Washington, DC
Pittsburgh, PA

Price of Lesson Package:  $ 525.00