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Youth Academy Online Registration

Please complete the entire Registration Form.

Make check payable to "NSA Youth Academy"

Do not forget to send a $50 deposit check or a check for the total amount to New Soccer Academy, 2828 W. Benjamin Dr., Wichita, KS 67204

Online registrations with out payments will not be considered as a complete registration.

 
 
Name *
Sex
   
Email Address *
 
Home Address *
 
City, State *
   
ZIP Code *
 
Birth Date *
 
Age *
 
Club Team *
 
Home Phone Number *
Cellphone Number
 
Parent or Guardian's Name *
 
Emergency Phone *
Select a program
Tuition $100 (only one discount applies)
Team Discount?
Team/Group Name
Number of Players in Group
Contact Name
Contact Telephone Number
How did you hear from us? Check all that apply



I certify that my child has been examined by a physician and found to be in good health and able to participate in all academy/clinic/camp activities without restriction.
Furthermore, I authorize the staff of New Soccer Academy to act for me according to his/her best judgment in an emergency requiring medical attention.
I hereby wave and release New Soccer Academy, and its staff from all claims resulting from any injury my child sustain while attending the clinic. New Soccer Academy is not responsible for personal items that are lost, stolen or damaged.
I also understand the camp retains the right to use any photographs, video tapes, motion picture recording or any other record of the event for publicity, advertising or any legitimate purpose.
 
Name of person filling out this registration (must be 18 or older) *
Electronic Consent?
 
Date *
 
Insurance Company's Name *
 
Policy Number *
Please Indicate your T-Shirt size
 
Login       Register

New Soccer Academy® - 2828 W. Benjamin Dr., Wichita, KS 67204 - Phone: (316) 650-9119 - Fax (316) 425-5518


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