Missouri State Soccer School Registration FormPlease print this form, fill in the information, and mail it to the address at the bottom of this page. |
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| Name: | |
| Address: |
| City: | State: | Zip: |
| Parent's Name: |
| Home Phone: | Work Phone: |
| Cell Phone | ||
| Email Contact: |
| Personal Information |
| Date of Birth: | Age: |
| Grade in school fall 2008: | Name of school: |
| Residential / Team Camps Only |
| Field Player | Goalkeeper |
| Roommate Preference: |
| Team Camp Only |
| Team Name: | Coach's Name and Phone: |
| Indicate Which Camps You Will Attend |
| Day Camp I: | June 9-12 | $165 |
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| Boy's Jr. Residential / Goalkeeper: | June 14-17 | $340 |
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| Boy's Jr. Commuter / Goalkeeper: | June 14-17 | $285 |
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| Girl's Residential / Goalkeeper: | June 21-25 | $435 |
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| Girl's Commuter / Goalkeeper: | June 21-25 | $355 |
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| Girl's Team Camp Residential: | June 26-29 | $355 |
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| Girl's Team Camp Commuter: | June 26-29 | $295 |
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| Day Camp II: | July 14-17 | $165 |
|
| Boy's Team Camp Residential: | July 22-25 | $355 |
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| Boy's Team Camp Commuter: | July 22-25 | $295 |
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| Boy's Residential / Goalkeeper: | July 26-30 | $435 |
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| Boy's Commuter / Goalkeeper: | July 26-30 | $355 |
| A $125 deposit is required for all Residential & Team camps ($30 deposit for all Day camps) Return this form with required deposit (payable to Missouri State Soccer School) |
| Select your T-shirt size |
| Youth: | M | L | Adult: | S | M | L | XL |
| Select size of soccer ball |
| Size 4 (ages 7-11) | Size 5 (ages 12 and up) |
| Total Enclosed: |
| Select method of payment |
| Check # | Cash |
| Discover | Visa | Mastercard |
| Credit/Debit Card # | Expiration Date:_____/_____/_____ |
| Cardholder Name: (print) |
| Cardholder Signature | Date: |
Mail To: |
Missouri State Soccer School |
| P.O. Box 7055 |
| Springfield, MO 65801-7055 |