Missouri State Soccer School Registration Form

2012 Missouri State Soccer School Registration Form Please print this form, fill in the information, and mail it to the address at the bottom of this page.
Name:

Address:

City:

State:

Zip:

Parent's Name:

Home Phone:

( )

Work Phone:

( )

Cell Phone:

( )

EMAIL Address (Return Information will be sent to this email) Print Clearly!:

Personal Information

Date of Birth:

Age: ________

Grade in school fall 2012:

Name of school:

Individual / Team Camps Only

Resident		Commuter
Field Player		Goalkeeper

Roommate Preference:

Team Camp Only

Team Name:

Coach's Name:

Indicate Which Camp You Will Attend			RESIDENT	COMMUTER
	Day Camp	June 5-8	NA	$200
	Boys Jr. Individual Camp	June 13-16	$375	$320
	Girls Team Camp	June 19-22	$390	$330
	Girls Individual Camp	June 23-27	$475	$395
	Boys Team Camp	July 17-20	$390	$330
	Boys Individual Camp	July 21-25	$475	$395

A $75 deposit is required for all Individual & Team camps ($50 deposit for Day Camp). Return this form with required deposit (payable to Missouri State Soccer School).

Select your T-shirt size

Youth:

Adult:

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

Missouri State Soccer School is owned and operated by Southwest Missouri Sports Camps, Inc.

2012 Missouri State Soccer School Registration Form