Bungee Soccer Registration

Bungee Soccer 2019

BEGINS: Wednesday, June 19, 2019
TIME: 6:15 – 9:15 p.m.
LOCATION: Valley Bible Church, 1477 Willow Avenue, Hercules
COST: $40 (includes a jersey) EARLY BIRD PRICE before JUNE 1: $35
In order to register online, you must have a valid credit card.
Register three friends that are new to our league, and you play for free! Be sure to send us the confirmations for your three friends' registrations if they register online.

Bungee Soccer Registration

* Student Full Name

* Address

* City

* State

* Zip Code

* Student Phone

* Student Email

* Birthdate

* Grade entering in the fall

* Is this your first year at Bungee Soccer?

If yes, how did you hear about us?

Name of friend who told you about Bungee Soccer

* Have you played soccer before?

If yes, what league?

* Shirt Size

Parent/Guardian Info

* Parent/Guardian Email

* Parent/Guardian Mobile Phone

* Opt-in for Team/League Updates

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

click here for help

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

By attending/participating in this activity/league, I understand that we will be participating in activities and may also be receiving food, beverages, and/or candy at this event. I also understand that photos or video may be taken and used by Valley Bible Church for promotional purposes only, and will not be sold to other parties. While measures are taken to ensure safety, as with any activity or event, there is a risk of sickness or injury. I fully accept this risk and hold harmless from any legal liability, Valley Bible Church and any staff, volunteers, or representatives involved in this activity/league.

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CONTACT US

Manny deSouza
Director of VBC Youth
(510) 799-3171
mdesouza@valleybible.org

Leila Aragon
Admin. Asst. for VBC Youth
(510) 799-3171 ext. 121
laragon@valleybible.org

PAYMENT QUESTIONS?

Ron Hughes
Church Administrator
(510) 799-3171 ext. 158
rhughes@valleybible.org

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Sunday Services

9:00am & 11:00am

Location

1477 Willow Avenue
Hercules, CA 94547 • 510-799-3171

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Bungee Soccer Registration

Bungee Soccer 2019