Bungee Soccer Late Registration

Parent/Guardian Info
Emergency Contact
Medical Information
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.)

Payment Selection


Billing Address

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

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