Duke Soccer Academy - Registration

Duke Soccer Academy - Registration

Participant Details
Number of child/children you would like to register:
Child 1 Name:*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Child 2 Name:*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Child 3 Name:*

First NameLast Name
Gender*

FemaleMale
Date of Birth*

MonthDayYear
Date
Participant Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Participant Phone Number*
Please enter a valid phone number.
Participant Email*
example@example.com
Education
Participant School*
High School Graduation Year*
Participant's Grade*
Playing Experience
Club Team*
If Other, Please Enter Below.
Other
Age Group
Emergency Contact Information
Name of Emergency Contact #1*

First NameLast Name
Phone Number of Emergency Contact #1*
Please enter a valid phone number.
Name of Emergency Contact #2*

First NameLast Name
Phone Number of Emergency Contact #2*
Please enter a valid phone number.
Insurance Information
Insurance Policy Holder Name*

First NameLast Name
Insurance Provider*
Insurance Provider Phone Number*
Please enter a valid phone number.
Insurance Policy Number*
Current Medications
Participant Allergies
Payment

My Products

Configurable list*
Should be Empty: