Soccer USA General Registration
Participant Information

Name: *

Please enter your name

Code:

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Date of Birth: *

Please select your Date of Birth

Age: *

Please enter age.

Sex:

Please choose sex.

Name:

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Date of Birth:

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Age:

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Sex:

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Session Location: *

Please enter session location.

Session Dates & Times: *

Please enter session dates & times

Parent Information

Name: *

Please enter parent name.

Street: *

please enter street.

City: *

Please enter city name.

Phone (Home):

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Phone (Cell):

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Please provide email address that is viewed regularly

E-Mail: *

Please enter valid email address.

Emergency Contact: *

Please enter emergency contact.

Emergency Phone: *

Please enter emergency phone.

Permission for Use of Photos - I give permission to Soccer USA to use my child/children for advertising purposes.

Please initial: *

Please write your initial.

I hereby authorize the director and staff of Soccer USA to act for me according to their best judgment in any situation requiring medical attention for my child. I hereby release, exonerate and discharge Scott Holt and Soccer USA. My son/daughter is healthy and capable of participating in this soccer activity. I will be responsible for any medical charges incurred and agree to the conditions of this agreement.

Signed: *

Please enter your signatures

Date: *

Please enter today date.

Promotion: How did you hear about us? We want to improve our customer service.

Word of Mouth:

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School:

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Internet:

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Advertisement:

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Other:

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Policies: A list of policies and procedures are posted on our website www.soccerforusa.com
Equipment: Soccer Ball - $15 Shin guards -$10 T-Shirt- $12
Camps: All Camp registration fees include a t-shirt
Clinics, classes and Training Sessions: T-shirts for sale (to keep costs down)
Programs: If you are doing a daily drop in, please circle days: Mon Tues Wed Thurs Fri
Overnight Camps: For Credit Card payments, deposits will be charged followed by full amount on due date
Family Discounts: Family Discounts – $5 discount for clinics and $10 discount for camps after first child has paid in full.


Payment

Do you have a promotion code:

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Which clients are you referring:

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Total Cost:

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Total Cost: Check- Make payable to Soccer USA
Credit Card –Visa or Master Card (Please Circle)

Credit Card #:

Please enter correct credit card number

Exp. Date:

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Security Code:

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(Security Code on back of card – 3 numbers)
Billing Address:

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(if different than above)
Name on Card:

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Signature:

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Date:

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Confirmation: Please note that your cleared check or processed credit card is confirmation of your Soccer USA Registration.
Complete Registration and return with check or credit card details mail to our Tempe location:
315 W. Elliot Rd. Suite 107-304, Tempe AZ 85284