Bungee Soccer Late Registration

* Student First Name

* Address

* City

* State

* Zip Code

* Student Phone

* Email to send registration confirmation

Student Email

* Birthdate

* Grade entering in the fall

* Is this your first year at Bungee Soccer?

How did you hear about Bungee Soccer? (Select that apply)

Name of friend who told you about Bungee Soccer

* Have you played soccer before?

If yes, what league(s)?

* Shirt Size

Parent/Guardian Info

* Parent/Guardian Email

* Parent/Guardian Mobile Phone

Emergency Contact

* First Name

* Last Name

* Phone Number

Medical Information

* Does your child have any health concerns or physical limitations that we need to know about?

If yes, please explain

* Date of Last Tetanus Shot

If your child should require medical attention for injuries received or illness contracted prior to this activity, give instructions here.

* Do you have Health Insurance?

* Insurance Company

* Insurance Company Address

* Policy Number

Medical Release

In the event that I cannot be reached in an emergency during this activity/league, I hereby give my permission to the physician or dentist selected by Valley Bible Church to hospitalize, to secure proper treatment, and/or an injection, anesthesia, or surgery for my child as deemed necessary. (Select yes below to agree.)

* I agree and give my permission

Payment Selection

* Registration Fee

Total Price:

$0.00

Billing Address

* Country

* Address

* City

* State

* Zip Code

Payment Information

* Credit Card Type

* Name on Credit Card

* Credit Card Number

* Expiration Date

* CCV Code

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CLICK THE SUBMIT BUTTON ONLY ONCE! Clicking twice may charge your card a second time.

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