EmailMe Form - 2016 Belmont United Fall Academy Registration

EmailMeForm

Player Name *
First Last

Gender *
Male
Female

Date of Birth
(Player) *
MM / DD / YYYY

Academy Option Desired
INDICATE PREFERRED OPTION (1-DAY/2-DAY)

Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Name *

Contact Email *

Cell Phone *
### - ### - ####

Home Phone *
### - ### - ####

Work Phone
### - ### - ####

Emergency Contact Name *

Cell Phone *
### - ### - ####

Home Phone *
### - ### - ####

Work Phone
### - ### - ####

Family Doctor

Doctor's Phone
### - ### - ####

Academy Shirt

T-Shirt Size

Medical Conditions & Allergies

Signed Medical Release Document (PDF or JPEG)

Terms Acceptance

I acknowledge *
I acknowledge that registered player has had, or will have, and appropriate physical exam before participating in the program

Season

Image Verification

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Belmont United Soccer Club is a 501c (3) compliant non-profit organization, Version 1/1/2012 P.O. Box 403, Belmont, CA 94002

Total $0.00