Registration

Success Four Three Eight

Academy - Soccer Registration Form

Ages 5 to 16 | Registration Fee: $40 | Monthly Fee: $100

Player Information

Player Full Name(Required)

First Last

Date of Birth(Required)

Age(Required)

Please enter a number from 5 to 16.

Ages 5 to 16

Gender(Required)

School Grade(Required)

Address & Parent / Guardian

Home Address(Required)

Street Address Address Line 2 City State ZIP Code

Parent / Guardian Name(Required)

Relationship(Required)

Phone Number(Required)

Second Parent Phone

Email Address(Required)

Emergency Contact

Emergency Contact Name(Required)

Emergency Contact Phone(Required)

Medical / Allergy Information

Medical / Allergy Information(Required)

List any medical conditions, allergies or medications the coach should know about. Write "None" if not applicable.

Uniform & Team

Shirt Size(Required)

Short Size(Required)

Position

Previous Team

Parent / Guardian Agreement

I hereby give permission for my child to participate in Success Four Three Eight Academy activities. I understand the risks in soccer training and games. I agree to the $40 registration fee and $100 monthly fee. I authorize emergency medical treatment if needed.

Agreement(Required)

I have read and agree to the Parent / Guardian Agreement above

Parent Signature(Required)

Payment

Monthly Fee

Price:

Registration Fee (one-time)

Price:

First Payment Total

Your first payment of $140 ($40 registration + $100 first month) is made securely through PayPal. After that, $100 is billed automatically every month. You can cancel the subscription anytime from your PayPal account.

Payment

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Registration

Success Four Three Eight

Academy - Soccer Registration Form

Player Information

Address & Parent / Guardian

Emergency Contact

Medical / Allergy Information

Uniform & Team

Parent / Guardian Agreement

Payment

Success 438

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