Program Registration

Registration Beginners U7-U9

Player Information

Player Full Name *

MM * 1 2 3 4 5 6 7 8 9 10 11 12

DD * 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31

YYYY * 2017 2016 2015 2014

Gender * Male Female

Email *

Home Address *

Do you have any special requests? *

Parent/Guardian Information

Parent/Guardian 1 Name *

Parent/Guardian 1 Cell Phone *

Parent/Guardian 1 Email *

Parent/Guardian 2 Name *

Parent/Guardian 2 Cell Phone *

Parent/Guardian 2 Email *

Practice Sessions

Select One * Soccer sessions

Jersey Size

Select One * YS/width 14in - length 20in YM/width 15in - length 21.5in YL/width 16in - length 22.5in YXL/width 17in -length 24in

Marketing

How did you hear about us? * Ashland Stingrays Swim Coach Current Club Member Facebook Friend or Family Google Instagram Internet Montclair moms! Online Return Player School Flyer The Montclairion Magazine Website

Emergency Contact Information

Primary Emergency Contact Person *

Relationship to Player *

Primary Emergency Contact Phone Number *

Secondary Emergency Contact Person (optional)

Relationship to Player (optional)

Secondary Emergency Contact Phone Number (optional)

Medical Information & History

Medical Insurance Company *

Medical Insurance Group Number *

Medical Insurance Policy Number *

Medical Insurance Phone Number *

Do you have any Allergies we need to be aware of? *

Yes

No

Please list your allergies *

Do you have medical conditions we need to be aware of? *

Yes

No

Please list any medical conditions we need to be aware of *

Please read and agree to the Club Policies & Waivers *

Yes

Si eres humano, deja este campo en blanco.

SUBMIT

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