Gold Star Soccer Year Round Program

Program
First Name
Last Name
Gender
Address
City
State
Zip Code
Date of Birth
Phone Number - Home
Phone Number - Cell
Emergency Phone
Parent First Name
Parent Last Name
E-Mail Address
T-Shirt Size
Allergies
Medical conditions
Players Physician
Physician Phone Number
Medical Insurance Company
Policy Holder
Policy Number
Group Number
How did you hear about us?
Promo Code
Medical Release
I have read and understand the above:

Electronic Signature
Date
By completing the registration form I do hereby allow Gold Star Soccer to use all photos taken during a Gold Star Soccer program to be used for merchandise and promotional use.