Slammers Soccer Academy - On Line Secure Player Registration

 

2010 Summer Skills Camp
July 5-8, 2010 (Monday - Thursday, 9:00am - 12:00pm)
Girls and Boys ages 6 to 14
   

Instructions

  
1
You must complete every space of the registration form.
2 Fields with a * must be completed without exception
3 Complete the Release of Liability Form (Click Here)
 
Player Information
* First Name  
Middle Initial  
* Last Name  
 
Month
Day
Year
* Date of Birth  
* Gender  
* Grade Entering in Fall  
 
     
* Address  
Address  
* City  
* State  
* Zip code  
* Player/Parent Email  
 
(example: name@xxxx.xxx,
  if none enter None)
 
  Area Code   Local Number
(
)   -
* Home Phone  
Cell Phone  
(
)   -
Sports Information
Team Played on 
     
Positions Played 
Forward
Midfield
 
Defender
Goalkeeper
Additional Comments (Enter any additional information, if no additional information, enter None)
* Medical Conditions (Please list any relevant medical conditions, allergies, and/or medication taken on a regular basis, if no medical conditions enter None. 200 letters max)
Parent/Guardian Information
* Parent/Guardian  
* First Name  
Middle Initial  
* Last Name  
   
* Home Phone  
  Area Code   Local Number
(
)   -
Work Phone  
(
)   -
Cell Phone  
(
)   -
email  
 
Additional Parent/Guardian  
First Name  
Middle Initial  
Last Name  
   
Home Phone  
  Area Code   Local Number
(
)   -
Work Phone  
(
)   -
Cell Phone  
(
)   -
email  
Emergency Contact Information    
First Name  
Last Name  
   

Home Phone  
  Area Code   Local Number
(
)   -
Work Phone  
(
)   -
Cell Phone  
(
)   -
 

* Do you have medical insurance Yes   No    

* What is the name of your Health Insurance Company

 
 
Session Information
Sumer Camp from July 5-8 (Monday - Thursday, 9:00am - 12:00pm)
$150.00
 Pay in Full
 
* Credit Card Payment Method
Program Information
How did you hear about our program  
   Referring Persons Name  
 
Payment Information
 
* Do not enter spaces or hyphens for the credit card number
* Enter credit card holders name exactly as it is on the credit card
* Credit Card Number 
* Expiration Date 
Month
  
Year
* First Name 
Middle Initial 
* Last Name 
 
* Enter credit card billing address and phone number
* Email address is for transaction confirmation
* Address 
* City/Town 
* State 
* Zip code 
* Phone 
  Area Code   Local Number
(
)   -
* Email 
By selecting the Continue button below you are giving authorization
for your credit card to be charged the Registration Fee amount indicated above
 
Slammers Soccer Academy
3122 Gibraltar Ave.
Costa Mesa, CA 92626
NOTICE: Please send a copy of this form along with your Liability Release Form to the address above.