Participant Information
Participant Name
*
First Name
Middle Name
Last Name
Birth Date
*
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Month
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Day
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Year
Gender
*
Please Select
Male
Female
N/A
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Player Picture
*
Passport or Birth Certificate
*
Email
example@example.com
Mobile Number
-
Area Code
Phone Number
Home Number
-
Area Code
Phone Number
School
Parent/Guardian Information
Parent/Guardian 1 Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Parent/Guardian 2 Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
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Emergency Contact & Medical Information
Primary Emergency Contact Name
*
First Name
Last Name
Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Relationship to Player
*
Does the player have any allergies we need to be aware of?
*
Yes
No
Please describe the player's allergies
Does the player have any other medical conditions that we should know of?
Yes
No
Please describe the player's medical conditions
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Waiver
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Training Locations
Which borough are you interested in receiving training at?
Bronx
Queens
Brooklyn
Manhattan
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Organization Options
Soccer Classes
*
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( X )
Youth Private Class - Individual
$70.00
$
70.00
One hour private training. It is recommended to train in groups of 4.
Quantity
1
2
3
4
5
6
7
8
9
10
Youth Private Class - Peer
$100.00
$
100.00
One hour private training for 2 students at once.
Quantity
1
2
3
4
5
6
7
8
9
10
Adult Private Classes - Individual
$70.00
$
70.00
One hour private training. It is recommended to train in groups of 4.
Quantity
1
2
3
4
5
6
7
8
9
10
Adult Private Classes - Peer
$100.00
$
100.00
One hour private training for 2 students at once.
Quantity
1
2
3
4
5
6
7
8
9
10
Group Private Class - Small
$120.00
$
120.00
One hour private training for up to 4 students at once.
Quantity
1
2
3
4
5
6
7
8
9
10
Group Private Class - Large
$180.00
$
180.00
One hour private training for up to 10 students at once.
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$0.00
$
0.00
Debit or Credit Card
First Name
Last Name
Credit Card Number
Security Code
Expiration Month
January
February
March
April
May
June
July
August
September
October
November
December
Expiration Month
Expiration Year
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
Expiration Year
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