2021 - 2022 Benfica | Verrado Soccer Club Registration
Player Name
*
First Name
Last Name
Player Date of Birth
*
-
Month
-
Day
Year
Date
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent Name | Guardian
*
First Name
Last Name
Cell Phone
*
-
Area Code
Phone Number
E-mail
*
Emergency Contact
Emergency Contact's Name
*
First Name
Last Name
Relationship
*
Please Select
Mother
Father
Grandparent
Aunt
Uncle
Sibling
Babysitter/Nanny
Other
Phone Number
*
-
Area Code
Phone Number
Do you have health insurance ?
*
Yes
No
Do you have any allergies, chronic illness, or medical conditions that would limit high level activtiy?
*
Yes
No
Signature
*
One time Fee
*
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2021-2022 Season Registration
$
185.00
Total
$
0.00
Payment Methods
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Card Expiration
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